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Home My WebLink AboutContract #: 004926 - From: To: - Exception - ExceptionSchool 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 144216 of the specifications and in any plans specified in such section, prepared by Kang Associates, Inc. for the School Department Administration Building,North Andover, MA for the contract sum of: Twenty Six Thousand Nine Hundred Sixty Three dollars ($ 26,963.00 ) B C For Alternate #1: No Change Deduct $ dollars ($ For Alternate #2: No Change Add/ Deduct $ dollars ($ For Alternate #3: No Change Deduct $ dollars ($ For Alternate #4: No Change Deduct $ dollars ($ For Alternate #5: No Change Deduct $ dollars ($ This sub -bid includes addenda numbered 1 This sub -bid ❑ may be used by any general bidder except: ❑ 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 19 years. 2. Ever failed to complete any work awarded? No 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. (a) Building Architect . General Contractor Amount of Contract 5 Western Avenue, Cambridge WT Rich $229,900 FORM OF SUB -BID - 2 School Department Administration Building North Andover, MA (b) (c) East Somerville School Leominster High School Kang Associates, Inc. January 2, 2014 Gilbane $109,900 WT Rich $139,900 4. Bank reference First Trade Union Bank 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. January 20, 2014 Date SUB -BIDDER'S CHECKLIST: Addenda Recognized Bid Deposit DCAM Certificate of Eligibility Sub -Bidder Update Statement Certificate of Corporate Bidder Eagle Elevator Co., Inc. (Name of Sub -Bidder) By: Signature and Title of Person Signing Bid Dan Wrenn, President 176 Norfolk Avenue Business Address Boston, MA 02119 City and State FORM OF SUB -BID - 3 School Department Administration Building North Andover, MA Paul Wrenn Vice President Bid Form, and that CERTIFICATE OF CORPORATE BIDDER Dan Wrenn Kang Associates, Inc. January 2, 2014 certify that I am the of the corporation named as Bidder in the who signed the Bid Form on behalf of the Bidder was then the President 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. /M Corporate Seal wocftdc Paul Wrenn, Vice President January 20, 2014 Date CORPORATE BIDDER -1 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. Signaturq Dan Wrenn, President Print Name & Title Date January 20, 2014 Eagle Elevator Co., Inc. Company Name 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. SignatureA Date January 20, 2014 Dan Wrenn, President Eagle Elevator Co., Inc. Print Name & Title Company Name CERTIFICATE OF TAX COMPLIANCE Pursuant to Chapter 62C of the Massachusetts General Laws, Section 49A (b), I Dan Wrenn , authorized signatory for Eagle Elevator Co., Inc. 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. !� January 20, 2014 ignature Date The Commonwealth of Massachusetts Executive Officefor Administration and Finance Division of Capital Asset Management and Maintenance One Ashburton Place DEVAL L. PATRICK Boston, Massachusetts 02108 GLEN SMOR GOVERNOR Tel: (617) 727-4050 SECRETARY. AOI WTRATION & Fax: (617) 727-5363 FINANCE 7'1MOTHY P. HURRAY UEmENANT GOVERNOR CAROLE CORNEUSON CORONER Filed Sub -Bid Certificate of Contractor Eligibility CON MCTOR IDENTIFICATION NUMBER: gM This C-awkate S all lk Used for Submi Filed Sub$ids Only 1. CERTIFICATION PERIOD: This Celrtifieate is valid from 7/12/2013 to 7/12/2014 2. CONTRACTOR'S NAME: Eagle Elevator Company, Inc. 3. CONTRACTOR'S ADDRESS: 176 Norfolk Avenue, Boston, MA 02119 4. WORK CATEGORIES: This Coutrader is certified to file bids ander Massaehnsetts general Laza Chapter 149, Chapter 149A and Chapter 2SA In the falioxing checked Categories of Worst: Acoustical cal Tele Electrical Work ❑ HVAC ❑ Lathing & Plastering ❑ Mi�lat m & Ornamental Iron Q Painting El Terrazzo Elevators ❑ Fire Protection Spm*ja Systems ❑ Marble ❑ Masa mY Work � Plumbing :3 Resilient Floors ❑ Tile El Waterproofing, Damp ❑ Glass and Glazing ❑ Metal Windows 0 hoofing & Flashing proofing, and Caulking S. EVALUATIONS: Number of Projects Evaluated: 13 Average Project Evaluation Rating: 88 Number of ProjeM Below Passing Score: 0 6. SUPPLIER DIVERSITY OFFICE RTIFICATI N: N/A r eyn & Berasteia, Deputy General Counsel, Approval Date for Carle I Comelimn, Commissioner NOTE TO C MNAM ae: CpVkHe APA s fior Renewiol of ContnactorEA Wlfty are due no lager N►mr — manths PNOR to the SWk adan Date of the Ce UROtlon Peeled shown above. Falun to suhMN Completed Appffwtlons dnrely may result in a gap In Certiffoation or a lapse in Cerepeatian oftgetherfor your company. Retrietwer's k"als Document A310 TM - 2010 Conforms with The American Institute of Architects AIA Document 310 CONTRACTOR: (Name, legal status and address) Eagle Elevator Company, Inc 176 Norfolk Ave., Roxbury, MA 02119 OWNER: (Name, legal status and address) Town of North Andover MA BOND AMOUNT: $ SURETY: (Name, legal status and prineipol place of business) North American Specialty Insurance Company 160 Gould Street, Suite 118 Needham, MA 02494 Five Percent of the Attached bid (5%) 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: (Name, location or address, and Project number, ifany) School Department Administration Building; Project: BDO-1408, Section: 144216 Elevators 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 die bid documents, or within such time period as may be agrWed 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 OlArrie • 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 tern 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 furnished, the intent is that this Bond shall be construed as a statutory bond and not as a common law bond. Signed and sealed this 21st day of January, 2014 (Witness) Eagle Elevator Company, Inc (Principal) (Seal) (Title) At'; North American Spec' Ity Insurance Company (surety) (Seal) (Witness) 6 (Title) AdamV. De anctis, Attorney -in -Fact NAS SURETY GROUP NORTH AMERICAN SPECIALTY INSURANCE COMPANY WASHINGTON INTERNATIONAL INSURANCE COMPANY GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, THAT North American Specialty Insurance Company, a corporation duly organized and existing under laws of the State of New Hampshire, and having its principal office in the City of Manchester, New Hampshire, and Washington International Insurance Company, a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of Schaumburg, Illinois, each does hereby make, constitute and appoint: JAMES J. AXON, GREGORY D. JUWA, MICHAEL F. CARNEY, WILDER PARKS, JR., PAUL A. PATALANO, ADAM W. DESANCTIS, MICHAEL T. GILBERT, CHRISTINE B. GALLAGHER, BRYAN F. JUWA, DAVID A. BOUTIETTE, RICHARD F. CARUSO and REBECCA SHANLEY JOINTLY OR SEVERALLY Its true and lawful Attomey(s}in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the amount of: FIFTY MILLION ($50,000,000.00) DOLLARS This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of Directors of both North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held on the 9d' of May, 2012: "RESOLVED, that any two of the Presidents, any Managing Director, any Senior Vice President, any Vice President, any Assistant Vice President, the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named in the given Power of Attorney to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is FURTHER RESOLVED, that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be binding upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached." �"\�IaUUlll7/r/rr�� ,aonrowaan v B ��2 OORPo T G c¢ S�L m= Steven P. Anderson, senior vice Presidcat of Washington International Insurance Company2 •' SEAL L cs sy 197J44i q & Senior Vke President of North American Specialty insurance Company E to t ?m nlnnma'� By David M. Layman, Vice President of Washington InterAtional Iasvrance Company & Vice President of North American Specialty insurance Company IN WITNESS WHEREOF, North American Specialty Insurance Company and Washington International Insurance Company have caused their official seals to be hereunto affixed, and these presents to be signed by their authorized officers this20th day of June 12012 , North American Specialty Insurance Company Washington International Insurance Company State of Illinois County of Cook ss: On this 20th day of June 2012 before me, a Notary Public personally appeared Steven P. Anderson , Senior Vice President of Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and David M. Layman , Vice President of Washington International Insurance Company and Vice President of North American Specialty Insurance Company, personally known to me, who being by me duly swom, acknowledged that they signed the above Power of Attorney as officers of and acknowledged said instrument to be the voluntary act and deed of their respective companies. +..+, "OFFICIALSEAL" /'��A n!J DONNA D. SKLENS Notary Public, State of Illinois Donna D. Sklens, Notary Public My CommissiooExpires tol06R0 15 I, Jeffrey Goldberg the duly elected Assistant Secretary of North American Specialty Insurance Company and Washington International Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said Nortb American Specialty Insurance Company and Washington International Insurance Company, Ewhich is still in full force and effect. M WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this U day of hLJaM , 20 lerfrey Goldberg, vice President & Assistant Secretary of Washington international Insurance Company & North American Spenalty Insurance Company EFFECTIVE MARCH 30, 2010 Commonwealth of Massachusetts Division of Capital Asset Management a 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 Prime/General 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. January 21,_2014 _ Bid Date School Department Administration Project Number (or Building name if no number) Town of North Andover Awarding Authority SIGNATUREc* _Eagle Elevator Company Print Name of Sub -bidder or Trade Contractor 176 Norfolk Ave Boston Ma 02119 Business Address 617-238-0613 Telephone Number dder's Authorized Representative Dan Wrenn, President Division of Capital Asset Management Page 1 of 18 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: www.mass.gov/dcam . 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 Qualifications It is the awarding authority's responsibility to determine each responsible bidder. You must consider all of the information in the bidder's 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 projected 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. The Awarding Authority shall advise DCAM of any material omissions in a Sub -bidder's Update Statement.. 1810 CMR 8.13(2)]. 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O L tp E C L OO >, C L M a o >1 E >, W 0 Q 0 00 0 v N N a 0 CV) U 0 09 U �W C C Co N y Cc m as �a U� ON C "0 0 c/n 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) 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 aproject? 2. Has your firm failed or refused either to perform or complete any of its work under any contract prior to substantial completion? 3. 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 ED 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 ❑ 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 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 ❑ payment bond on any contract? 8. Has any subcontractor filed a demand for direct payment with an awarding authority ❑ 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 under any of your contracts? 10. Have there been any deaths of an employee or others occurring in connection with any of yourprojects? 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 ear? Division of Capital Asset Management Page 16 of 18 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 "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 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 16 of 18 Sub -bidder Update Statement Effective March 30, 2010 PART 4 - Legal or Administrative Proceedings; Compliance with Laws (continued) YF,C Nn 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 relation? 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? 10. Has your firm been fined by OSHA or any other state or federal agency for ❑ violation of any laws or regulation 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? 12. Other than previously reported in the above paragraphs of this Section I, have any El 0 administrative proceedings or investigation 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 ❑ responsibility and integrity as a building contractor? Division of Capital Asset Management Page 17 of 18 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. NAME TITLE OR FUNCTION Daniel Wrenn President Paul Wrenn Vice President Marc Cirulnick Project Manager Michael Pierce Sales Manager 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 18 of 18 Sub -bidder Update Statement Effective March 30, 2010 G. Completed Projects List all building construction projects of at least $80,000, which your firm has completed within the past five years or the twenty most recent projects completed within the past five years that are at least $80,000. Do not list projects with contract values less than $80,000. Information on randomly selected projects is not acceptable. Note: when listing requested Categories of Work, refer to categories from page 9 of this application. List all relevant categories of work that your firm performed with its own employees for each project. With respect to single contracts involving multiple categories of work, provide a dollar breakdown attributable to each category listed. Do not list highway, bridge, tunnel, sewer, site work, or other horizontal projects that do not involve buildings. Attach additional sheets, if necessary. 1. Project Title: Fitchburg State College — Science Bldg. Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevators $169,000 Category 2) $ Category 3) $ Total Contract Amount: $169,000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Fitchburg, MA Start / End dates: 12/1/12 — 4/1/2013 Owner: Fitchburg State College Contact Person: Mr. Michael McKinney Telephone Number: 978-345-2151 Complete Mailing Address: 160 Pear Street, Fitchburg, MA 01420 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Bond Brothers Contact Person: Mr. Jonathan Silva Telephone Number: 617-387-3400 Complete Mailing Address: 145 Spring Street, Everett, MA 02149 Page 23 of 36 2. Project Title: East Somerville School Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elelvator $108,900.00 Category 2) $ Category 3) $ Total Contract Amount: $108,900.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): East Somerville, MA Start / End dates: 611/2012 — 4/10113 Owner: City of Somerville Contact Person: Ms. Angela Allen Telephone Number: 617-625-6600 Complete Mailing Address: 93 Highland Avenue, Somerville, MA 02143 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Gilbane Building Company Contact Person: Mr. Michael Marcella Telephone Number: 617-478-3300 Complete Mailing Address: 58 Saville Avenue, Quincy, MA 02169 G. Completed Projects (continued) 3. Project Title: 5 Western Avenue, Cambridge Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $289,500. 00 Category 2) $ Category 3) $ Total Contract Amount: $289,500. 00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Cambridge, MA Start / End dates: 211/12 — 4/10/13 Owner: Cambridge Housing Authority Contact Person: Mr. Robert Labrecqui Telephone Number: 617-520-6237 Complete Mailing Address: 166 Prospect Street, Cambridge, MA 02139 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: W. T Rich Company Contact Person: Jonathan Rich Telephone Number: 617-590-4702 Complete Mailing Address: 29 Crafts Road, Newton, MA 02458 Page 24 of 36 4. Project Title: Holiday Inn Express Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevators $179, 000.00 Category 2) $ Category 3) $ Total Contract Amount: $179,000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Boston, MA Start / End dates: 5/1112 — 2115113 Owner: Gemini Properties Contact Person: Mr. Ritesh .Iariwala Telephone Number: 212-871-6280 Complete Mailing Address:200 Park Avenue/Suite 1305, New York, NY 10003 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Construction Consultants Contact Person: Mr. Paul Donovan Telephone Number: 617-894-2511 Complete Mailing Address: G. Completed Projects (continued) 5. Project Title: Springfield Data Center Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevators $399,900.00 Category 2) $ Category 3) $ Total Contract Amount: $ 399,900. 00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Springfield, MA Start / End dates: 5/1/12 — 2/15/13 Owner: Division of Capital Asset Management Contact Person: Mr. Don Mailoux Telephone Number: 617-727-4050 Complete Mailing Address: This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Skanska USA Building, Inc. Contact Person: Mr. Mike Shunta Telephone Number: 413-886-0125 Complete Mailing Address:59 Spring Street, Springfield, M4 01105 Page 25 of 36 6. Project Title: Connolly Acura Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $101,000.00 Category 2) $ Category 3) $ Total Contract Amount: $101, 000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Framingham, MA Start / End dates: 7/1/12 — I1-20-12 Owner: Claremont Realty Trust Contact Person: Telephone Number: Complete Mailing Address: 37 Oliver Street, Belmont, MA 02178 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: MBM Construction Contact Person: Mr. Dan Dudek Telephone Number: 781-856-2001 Complete Mailing Address: 7 Oakledge Road, Wakefield, MA 01880 G. Completed Projects (continued) 7. Project Title: 165 Newbury Street Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $119,900.00 Category 2) $ Category 3) $ Total Contract Amount: $119,900.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. Elevator $119,900.00 2. $ 3. $ Project Location (city & state): Boston, MA Start / End dates: 4/1/12 —10/25/12 Owner: 165 Newbury Street, LLC Contact Person: Mr. David Graham Telephone Number: 781-926-6280 Complete Mailing Address: 165 Newbury Street, Boston, MA 02116 This project was managed by a: Construction Manager ❑ General Contractor ❑ Architect/Designer ❑ (check one) Name of Firm: Contact Person: Telephone Number: Complete Mailing Address: Page 26 of 36 8. Project Title: Bergen Circle Apartments Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $301,000.00 Category 2) $ Category 3) $ Total Contract Amount: $301,000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Springfield, MA Start / End dates: 08/16/11-11/11/12 Owner: Century Pacific Housing Partnership Contact Person: Mr. Gene Langon Telephone Number: 732-367-0129 Complete Mailing Address: 195 Cedar Bridge Avenue/Suite One, Lakewood, NJ 08701 This project was managed by a: Construction Manager ® General Contractor ❑ Architect/Designer ❑ (check one) Name of Firm: George D. Cattabiani Contact Person: Mr. George Cattabiani, Jr. Telephone Number: 201-768-7331 Complete Mailing Address: G. Completed Projects (continued) 9. Project Title: Rogers Middle/High School Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $123,600. 00 Category 2) $ Category 3) $ Total Contract Amount: $123,60. 00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state):Boston, MA Start / End dates: 2/1/11— 7/25/12 Owner: Town of Rockland Contact Person: Telephone Number: 781-871-1892 Complete Mailing Address:242 Union Street, Rockland, MA 02370 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Agostini Construction Company Contact Person: Mr. Ron Lanzieri Telephone Number: 401-431-1200 Complete Mailing Address: 243 Narragansett Park Drive, Rumford, RI 02916 Page 27 of 36 IO.Project Title: Northampton Police Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $112,900.00 Category 2) $ Category 3) $ Total Contract Amount: $112,900.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Northampton, MA Start / End dates: 2/1/11— 5/22-12 Owner: City of Northampton Contact Person: Telephone Number: Complete Mailing Address: This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Barr & Barr Contact Person: Mr. Jason Boudrea Telephone Number: 413-739-6257 Complete Mailing Address: 32 Hampden Street, Springfield, MA 01103 G. Completed Projects (continued) I I .Project Title: West Point, Building 757 Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevators $487,000.00 Category 2) $ Category 3) $ Total Contract Amount: $487, 000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Westpoint, NY Start / End dates: 6/11/11 — 12/1 /11 Owner: United States Military Academy Contact Person: Director of Public Works Telephone Number: Complete Mailing Address: Building 667A, West Point, NY 10996 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Consigh Construction Contact Person: Ms. Janice Norowski Telephone Number: 508-458-0392 Complete Mailing Address: 72 Summer Street, Milford, MA 01757 Page 28 of 36 12.Project Title: Abbott Elementary School Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $85,900.00 Category 2) $ Category 3) $ Total Contract Amount: $ 85,900. 00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Westford, MA Start / End dates: 9/1/11-11/I1/11 Owner: Westford Public Schools Contact Person: Mr. Bill Olsen Telephone Number: 978-692-5560 Complete Mailing Address: 23 Depot Street, Westford, MA 01886 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Eagle Point Builders Contact Person: Mr. Marc Moroso Telephone Number: 617-484-3664 Complete Mailing Address: 54 Burnham Street, Belmont, MA 02478 G. Completed Projects (continued) 13.Project Title: Medford Housing Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $498,400.00 Category 2) $ Category 3) $ Total Contract Amount: $498,400.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: Project Location (city & state): Medford, MA Start / End dates: 5/1/11-11/30/11 Owner: Medford Housing Authority Contact Person: Mr. John Lonergan Telephone Number: 781-396-7200 Complete Mailing Address: 121 Riverside Avenue, Medford, MA 02155 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Prism Builders Contact Person: Mr. Matt Genzale Telephone Number: 781-246-1900 Complete Mailing Address: 107 Audubon Road, Wakefield, MA 01880 Page 29 of 36 14.Project Title: 27 Eddy Street Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $181,000.00 Category 2) $ Category 3) $ Total Contract Amount: $181,000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. Elevator $181,000 2. $ 3. $ Project Location (city & state): Boston, MA Start / End dates:9/1/11-11/30/11 Owner: Cornish Associates Contact Person: Mr. Steve Durkee Telephone Number: 401-276-1175 Complete Mailing Address: 46 Aborn Street, Providence, RI 02963 This project was managed by a: Construction Manager ❑ General Contractor ❑ Architect/Designer ❑ (check one) Name of Firm: Contact Person: Telephone Number: Complete Mailing Address: G. Completed Projects (continued) 15. Project Title: Newport Naval Base Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $84, 000.00 Category 2) $ Category 3) $ Total Contract Amount: $84,000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state):Newport, RI Start / End dates:01/01/11 / 08/30/11 Owner: Department of Navy Contact Person: Telephone Number: Complete Mailing Address: OICC/ROICC, Narragansett Bay Area, Newport, RI 02841 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: J & J Contractors Contact Person: Kam Patel Telephone Number: 978-452-9898 Complete Mailing Address: 35 Market Street/Suite 401, Lowell, MA 01852 Page 30 of 36 16.Project Title: Worcester North High School Enter all appropriate Categories) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $372,000.00 Category 2) $ Category 3) $ Total Contract Amount: $372,000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Worcester, MA Start / End dates: 10/1/10 — 7/31/11 Owner: Worcester Public Schools Contact Person: Mr. Dominic Lanzillotti Telephone Number: 508-799-3121 Complete Mailing Address: 140 Harrington Way, Worcester, MA 01609 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Gilbane Building Company Contact Person: Mr. Scott McCellan Telephone Number: 413-230-2069 Complete Mailing Address: 7 Jackson Walkway, Providence, RI 02903 G. Completed Projects (continued) 17. Project Title: Devens Air Force Base Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elelvator $85,000.00 Category 2) $ Category 3) $ Total Contract Amount: $85, 000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Devens, MA Start / End dates: 2/1/11- 7131/11 Owner: US Army Corp. of Engineers Contact Person: Telephone Number: 978-772-0148 Complete Mailing Address: 50 McCarthur Avenue, Devens, MA 01434 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: J & J Contractor Contact Person: Mr. Dave Seemon Telephone Number: 978-452-9898 Complete Mailing Address: 35 Market Street/Suite 401, Lowell, MA 01852 Page 31 of 36 18. Project Title: Goodyear Elementary School Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $105,500.00 Category 2) $ Category 3) $ Total Contract Amount: $105,500.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Woburn, MA Start / End dates: 3/1111- 7131111 Owner: City of Woburn Contact Person: David Dunkley Telephone Number: 781-897-5800 Complete Mailing Address: 41 Central Street, Woburn, MA 01801 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: Gilbane Building Company Contact Person: Mr. Kevin Jones Telephone Number: 413-230-2069 Complete Mailing Address: 7 Jackson Walkway, Providence, RI 02903 G. Completed Projects (continued) 19.Project Title: Western Mass Hospital Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $87,000.00 Category 2) $ Category 3) $ Total Contract Amount: $87, 000.00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. Elevator $ 87, 000.00 2. $ 3. $ Project Location (city & state): Westfield, MA Start / End dates: 511111— 6/30111 Owner: Western Mass Hospital Contact Person: Ms. Christina Boddendors Telephone Number: 413-562-4131 Complete Mailing Address: 91 East Mountain Road, Westfield, MA 01085-1889 This project was managed by a: Construction Manager ❑ General Contractor Architect/Designer ❑ (check one) Name of Firm: JK Scanlon Company Contact Person: Craig Gabri Telephone Number: 508-540-6226 Complete Mailing Address: 15 Research Road, East Falmouth, MA 02356 Page 32 of 36 20. Malden Government Center Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Elevator $95,400.00 Category 2) $ Category 3) $ Total Contract Amount: $95,400. 00 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. Elevator $95,400.00 2. $ 3. $ Project Location (city & state): Malden, MA Start / End dates: 311111- 4130/11 Owner: Government Center Commission Contact Person: Mr. Steve Melanson Telephone Number: 781-397-7070 Complete Mailing Address: 200 Pleasant Street/Room 419, Malden, MA 02148 This project was managed by a: Construction Manager ❑ General Contractor ❑ Architect/Designer ❑ (check one) Name of Firm: N/A Contact Person: Telephone Number: Complete Mailing Address: Regarding the information you supplied in Sections E, F, and G above: is your firm or any individual who owns, manages or controls your firm affiliated with any owner, designer or general contractor named in Sections E, F, and G either through a business or family relationship? (click one) ❑ yes ® no are any of the contact persons named in Sections E, F, and G affiliated with your firm or any individual who owns, manages or control your company, either through a business or family relationship? (click one) ❑ yes ®no If you have answered yes to either question, please explain. Attach additional sheets, if necessary. H. General Performance Answer the following questions by using your cursor to click YES or NO. Information is to cover the past five years prior to the date of submission of this application. For Sections "H" and "I", if you answer YES to any question, please provide on a separate page a complete explanation. Include all details [project name(s) and location(s), names of all parties involved, relevant dates, etc.]. IF YOU HAVE ANY DOUBT AS TO WHETHER TO ANSWER "YES" IT IS BETTER TO BE OVER INCLUSIVE AND TO PROVIDE A DETAILED EXPLANATION. YF,S 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 aproject? 2. Has your firm failed or refused either to perform or complete any of its work under any contract prior to substantial completion? 3. 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 ❑ 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 been an officer, principal or individual with a financial interest in another firm that hada payment or perfortnance bond invoked? 7. Has your surety made payment to a materials supplier or other party under your ❑ payment bond on any contract? 8. Has any subcontractor filed a demand for direct payment with an awarding authority 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 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 Page 33 of 36 Prime/General Revised January 2009 Computer your projects resulting in their inability to return to work for a period in excess of one year9 Page 33 of 36 Prime/General Revised January 2009 Computer I. Legal or Administrative Proceedings; Compliance with Laws Please answer the following questions. Information is to cover all judicial and administrative proceedings involving applicant's firm, which were instituted or concluded (adversely or otherwise) within the past five years prior to the date of submission of this application. The term "administrative proceeding" as used in this application for certificate of eligibility 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.). IF YOU HAVE ANY DOUBT AS TO WHETHER TO ANSWER "YES" IT IS BETTER TO BE OVER INCLUSIVE AND TO PROVIDE A DETAILED EXPLANATION. ira-DRIEWT11 1. Within the past 5 years 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. Within the past 5 years 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. Within the past 5 years 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. Within the past 5 years have any judicial or administrative proceedings involving 11 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? Page 34 of 36 I. Legal or Administrative Proceedings; Compliance with Laws (continued) G�� k M 5. Within the past 5 years 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. Within the past 5 years 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. Within the past 5 years 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. Within the past 5 years 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 contractin ? 9. Within the past 5 years 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? 10. Within the past 5 years 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: this information may be obtained from OSHA's Web Site at www.osha. ov 11. Within the past 5 years has your firm been sanctioned for failure to achieve ❑ DBE/MBE/WBE goals, workforce goals, or failure to file certified payrolls on any publicprojects? 12. Other than previously reported in the above paragraphs of this Section I, within the ❑ past 5 years have 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? 13. Are there any other issues that you are aware which may affect your firm's ❑ responsibility and integrity as a building contractor? Page 36 of 36 Prime/General Revised January 2009 Computer L Certification (notarization required) The undersigned, Da" Wrenn hereby certifies: (type name) That I am an owner or principal of Eagle Deviator Co., Inc_, (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 April 4 2013 This 3rd day of AITJ1 2013. By (signature): Type name: Title or position: Sg-z(� 1 Y—. ss. (county) Dan Wreim President (state) Before me, s(l t L nally appeared and (notary public) known to me to be2NUOf� based (name of officer) on satisfactory evidence which was his/her driver's license and acknowledged that helshe is authorized to execute the foregoing and that its execution is his/her free a act and deed o€th"ra **Upon My commission and the two corresponding Exct email them to CertiocatiopApulicatioadcam atate.ma.ua ** Page 16 of 16 PrimetGeneral Beriwd March 2011 COIDPO r