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Matich Corporation BidSECTION 1200 BID DATE: July 29, 2020 The undersigned, as bidder, declares it has received and examined the Contract Document entitled Project No. 2020-04, Washington Street Pavement Rehabilitation, and will contract with the City, on the form of Contract provided herewith, to do everything required for the fulfillment of the contract for said work at the prices and on the terms and conditions herein contained. We have included the following items and agree that they shall form a part of this bid: SECTION TITLE 1200 Bid 1210 Bid Schedule 1220 Bid Guaranty Bond 1230 Certification of Bidder's Experience and Qualifications 1240 Proposed Subcontractors 1250 Non -Collusion Affidavit 1260 DIR Project Vendor Information We acknowledge that the following addenda have been received and have been examined as part of the Contract Documents. Bidders must be on the Plan Holders List with the City of La Quinta in order to receive addenda. Addendum # Date Received Initials 1 iuly 27, 2020 AqWl Attached is a bid guaranty bond as required by Paragraph 1110-15.0, BID Matich Corporation Name of Bidder 909)382-7400 Bidder's Telephone Number Bid 1200-1 If our bid is accepted, we agree to sign the contract without qualifications and to furnish the performance and payment bonds and the required evidence of insurance within 10 calendar days after receiving written notice of the award of the contract. We further agree, if our bid is accepted and a Contract for performance of the work is entered into with the City, to so plan work and to prosecute it with such diligence that the work shall be completed within the time stipulated. Matich Corporation Name of Bidder 1596 Harry Sheppard Blvd., San Bernardino, CA 92408 Bidder's Address 149783 Contractor's License No. California State of Incorporation Signature of Bidder Robert M. Matich Printed Name of Signatory Vice President Title of Signatory 909)382-7400 Bidder's Telephone Number rmatich@matichcor .om Bidder's Email Address November 30.2020 Contractor's Expiration Date Secretary / Treasurer - Randall S. Valadez Title of Witness Bid 1200-2 ADDENDUM 01 — JULY 24, 2020 SECTION 1210 BID SCHEDULE PROJECT NO. 2020-04 WASHINGTON STREET PAVEMENT REHABILITATION City of La Quinta 78-495 Calle Tampico La Quinta, CA 92253 To Whom It May Concern: Pursuant to the Invitation to Bid, and in accordance with the provisions therein stated, the undersigned hereby proposes and agrees that on award by the City under this Bid, to execute a Contract, with necessary bonds, to furnish and install any and all labor, materials, transportation and services for Project No. 2020-04, Washington Street Pavement Rehabilitation, in accordance with the plans and specifications therefore adopted and on file with the City within the time hereinafter set forth and at the prices named in this Bid. It is understood that the basis of award shall be the lowest total price of the Base Bid Area plus All Additive Alternates. Unit prices in each and every case represent the true unit price used in preparing the bid schedule totals (Bid Form). Unit prices listed herein include material, installation and appurtenant work as is necessary to have the item complete and in place meeting the full intent of the plans and specifications. We acknowledge that unbalanced unit prices shall be sufficient cause for the rejection of our bid. Bid Schedule 1210-1 ADDENDUM 01 — JULY 24, 2020 BASE BID — WASHINGTON STREET PAVEMENT REHABILITATION Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Mobilization 1 LS $ , OT $ Olt " 2 Traffic Control 1 LS $ 3 $�� a 3 Dust Control 1 LS $ $ 4 2" Grind and Overlay 360,479 SF $ / $? —7 3Z Continue to Full Depth Asphalt Concrete Grind 5 (3.5"f), Compact Existing 1 275 SF -70 $ Aggregate Base, and 5.5" Asphalt Concrete Overlay to Bottom of Final Lift Remove and Construct 5.5" 6 AC over 6.5" AB, CLQ STD. 321 SF $ 195 l Remove Existing Concrete 7 Sidewalk, Ramps, and 5,105 SF $ Cross -Gutters Remove Existing Curb and 8 Curb & Gutter (Regardless 307 LF $ 7 , $ 7f of Height) 9 Crack Seal and Type II 11,157 SF $ SlurrySeal Construct Curb & Gutter per 10 City of La Quinta Std. Dwg. 307 LF 201and 202 (Regardless of Height) Construct Sidewalk per City 11 of La Quinta Standard 240 615 SF $ $ %O Mod. Construct Concrete Curb 12 Ramps per City of La Quinta 9 EA $ <500— $cam 7� Standard 250 Mod. Construct Portion of Cross- 13 Gutter per City of La Quinta 735 SF $ S� �� .�. $_� STD 230 Mod. and 231 Mod. 14 Lower and Raise Drainage 1 EA $ $ r' Manhole to Grade 15 Striping and All Incidentals 1 LS $ yr�(Xa- $ Total Amount Amount of Bid Items 1 — 15 $ Bid Schedule 1210-2 ADDENDUM 01 - JULY 24, 2020 City may award all or none of the following additive alternates: ADDITIVE ALTERNATE No. 1 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Lower Sewer Manhole per 9 EA $ f CVWD Standards 2 Raise Sewer Manhole per 9 EA ,�� $ ���J 1 $��i'S CVWD Standards Total Amount of Bid Items 1 - 2 $ ADDITIVE ALTERNATE No. 2 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Lower Water Valve per 19 EA �° $ y%C� $ CVWD Standards 2 Raise Water Valve per 19 EA $ $/� CVWD Standards Total Amount of Bid Items 1 - 2 ADDITIVE ALTERNATE No. 3 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Lower Irrigation Valve per 3 EA $ cl -- $ % L 0;76 .. CVWD Standards 2 Raise Irrigation Valve per 3 L EA $ $ - -- CVWD Standards Total Amount of Bid Items 1 - 2 $ ADDITIVE ALTERNATE No. 4 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Lower Frontier Manhole with 1 EA $ 200 $ 70C Vehicle Traffic Rated Ca Total Amount of Bid Items 1 $ Bid Schedule 1210-3 ADDENDUM 01 - JULY 24, 2020 ADDITIVE ALTERNATE No. 5 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 2" Grind and Overlay with 504 SF $ S1 $ Pavement Fabric / Replace obliterated striping, pavement markings, and 2 pavement markers in 2" Grind and Overlay with 1 LS Pavement Fabric construction area. Total Amount of Bid Items 1 — 2 $ �Z GRAND TOTAL BASE BID PLUS ALL ADDITIVE ALTERNATES(Figures): $ I `-` b I GRAND TOTAL BASE BID PLUS ALL ADDITIVE ALTERNATES (Words): Bid Amount of each of the above Bid Items must be filled in and completed. It is understood that the quantities shown hereon are but estimates and the bidder is responsible to verify quantities prior to submitting a bid. Final payment will be based upon actual work performed, subject to such adjustments and alterations as elsewhere provided herein. 4 W Signature of Bidder (Ink) Robert M. Matich - Vice President Name of Bidder (Printed or Typed) 909)382-7400 Bidder Telephone Number rmatich@matichcorp.com Bidder Email Address Bid Schedule 1210-4 SECTION 1220 BID GUARANTY BOND PRINCIPAL, and Liberty Mutual Insurance Company , as SURETY, are held and firmly bound unto the City in the penal sum of TEN (10) PERCENT OF THE TOTAL AMOUNT OF THE BID of the Principal above named, submitted by said Principal to the City for the work described below, for the payment of which sum in lawful money of the United States, well and truly to be made to the City to which said bid was submitted, we bind ourselves, our heirs, executors, administrators, and successors, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH THAT WHEREAS, the Principal has submitted the above -mentioned bid to the City, for certain construction specifically described as follows, for which bids are to be opened at La Quinta, California. PROJECT NO. 2020-04 WASHINGTON STREET PAVEMENT REHABILITATION NOW, THEREFORE, if the aforesaid Principal is awarded the contract and, within the time and manner required under the specifications, after the prescribed forms are presented to him/her for signature enters into a written contract in the prescribed form, in accordance with the bid, and files two bonds with the City, one to guarantee faithful performance, and the other to guarantee payment for labor and materials as required by law, and provide certificate of insurance coverage required by the Contract Documents, then this obligation shall be null and void; otherwise, it shall be and remain in full force and virtue. IN WITNESS WHEREOF, we have hereunto set our hands on this 27th day of July 2020. Matich Corporation Signature of Principal 1596 Harry Sheppard Blvd., San Bernardino, CA 92408 Liberty Mutual Insurance Company Reece Joel Diaz, Attorney -in -Fact Title of Signatory (L d A L Signatuk6 of Surety 790 The City Drive South, Suite 200, Orange, CA 92868 Address Address Note: Signatures of those executing for the surety must be properly acknowledged. Bid Guaranty Bond 1220-1 CALIFORNIA ALL- PURPOSE CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of San Bernardino On July 28, 2020 before me, Sammi Jo Shubin, Notary Public , (Here insert name and title of the o -cer) personally appeared Robert M. Matich who proved to me on the basis of satisfactory evidence to be the person(s) whose name(-&) is re subscribed to the within instrument and acknowledged to me that < fihe/they executed the same in is er/their authorized capacity(ies), and that by Is er/their signature(a) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. ata WMWi ESS my h nd and official seal. Puhlic {9 afore (Notary Public Seal) ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT (Title or description of attached document) (Title or description of attached document continued) Number of Pages Document Date CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) ❑ Corporate Officer (Title) ❑ Partner(s) ❑ Attorney -in -Fact ❑ Trustee(s) ❑ Other www.NotaryClasses.com 800-873-9865 s _ , SAMMI JO SHUBIN Notary Public - California San Bernardino County r iy Commission N 2279094 My Comm. Expires Feb 28, 2023 INSTRUCTIONS FOR COMPLETING THIS FORM This form complies with current California statutes regarding notary wording and, if needed, should be completed and attached to the document. Acknowledgments from other states may be completed for documents being sent to that state so long as the wording does not require the California notary to violate California notary law. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. he/she/the} is /are ) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re -seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. Indicate title or type of attached document, number of pages and date. Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document with a staple. CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 �A notary public or other officer completing this certificate verifies only the identity of the individual who signed the ` document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Orange On `•p U L 2 7 2020 before me, Date personally appeared ) Heather Rose Saltarelli, Notary Public Here Insert Name and Title of the Officer Reece Joel Diaz Name(s) of Signer(s) - - - - who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. HE Lary bisF s dltf rnu Notary pudic - Californi! Signature!-i/L __ J z Grange Ceun2.y Comm;s5farr r 2246219 - Signatun? of Noiary Public MY Cemrr, ExaF-!s 1�[ 77, ]027. Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Document Date. Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name:. Corporate Officer — Title(s): Partner -- Limited i_ General Individual i� Attorney in Fact Trustee !-! Guardian or Conservator Other: Signer Is Representing: Signer's Name: Corporate Officer — Title(s): Partner — !Limited General .'Individual i_J Attorney in Fact Trustee Guardian or Conservator Other: Signer Is Representing:.. x� 02014 National Notary Association - www.NationaiNotary.org - 1-800-US NOTARY (1-800-876-6827) Item #5907 This Power of Attorney limits the acts of those named herein, and they have no authority to bind the Company except in the manner and to the extent herein stated. Liberty Mutual„ SURETY Liberty Mutual Insurance Company The Ohio Casualty Insurance Company West American Insurance Company POWER OF ATTORNEY Certificate No: 8201964-977460 KNOWN ALL PERSONS BY THESE PRESENTS: That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire, that Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts, and West American Insurance Company is a corporation duly organized under the laws of the State of Indiana (herein collectively called the "Companies"), pursuant to and by authority herein set forth, does hereby name, constitute and appoint, Rhonda C. Abel; Jeri Apodaca; Reece Joel Diaz: Maria Guise: Kim Luu; Michael D. Parizino; Rachelle Rheault: Heather Saltarelli: James A. Schaller all of the city of Nen ❑rt Beach state of Cal lfbmia each individually if there be more than one named, its true and lawful attorney -in -fact to make, execute, seal, acknowledge and deliver, for and on its behalf as surety and as its act and deed, any and all undertakings, bonds, recognizances and other surety obligations, in pursuance of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons. IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed thereto this 23rd day of August 2019 . State of PENNSYLVANIA CU County of MONTGOMERY V a) ocu N > m� _CU ('w aP UY O O � c� > N r � 0 Z U Liberty Mutual Insurance Company P� iNSU,p� golf IN& %NSU The Ohio Casualty Insurance Company EJ `p+epoRgr Bn qJ o�O74ry -? 4anPo r�r yn West American Insurance Company Fa m 1912 0 1919 1991 ❑ g�$�CHug� a so �sykAMPBa�%L Y rNpIAHP b� 3�■� { t �y� * f�° S3M * ��d By: David M. Carey, Assistant Secretary this 23rd day of August�, 2019 before me personally appeared David M. Carey, who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance npany, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do, execute the foregoing instrument for the purposes rein contained by signing on behalf of the corporations by himself as a duly authorized officer. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my notarial seal at King of Prussia, Pennsylvania, on the day and year first above written. PAS,, TIC COMMONWEALTH OF PENNSYLVANIA Notarial Seal OF Teresa Pastella, Notary Public Upper MerionTwp., Montgomery County By: §' My Commission Expires March 28,202 nm� y Member, Ponnay[rania As5o[ia@6n W Notaries %N Public This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows: ARTICLE IV — OFFICERS: Section 12. Power of Attorney. Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject to such limitation as the Chairman or the President may prescribe, shall appoint such attomeys-in-fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Such attomeys-in-fact, subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so executed, such instruments shall be as binding as if signed by the President and attested to by the Secretary. Any power or authority granted to any representative or attorney -in -fact under the provisions of this article may be revoked at any time by the Board, the Chairman, the President or by the officer or officers granting such power or authority. ARTICLE XIII — Execution of Contracts: Section 5, Surety Bonds and Undertakings. Any officer of the Company authorized for that purpose in writing by the chairman or the president, and subject to such rtmitatlons as the chairman or the president may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Such attorneys -in -fact subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so executed such instruments shall be as binding as if signed by the president and attested by the secretary. Certificate of Designation — The President of the Company, acting pursuant to the Bylaws of the Company, authorizes David M. Carey, Assistant Secretary to appoint such attorneys -in - fact as may be necessary to act on behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Authorization — By unanimous consent of the Company's Board of Directors, the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the Company, wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds, shall be valid and binding upon the Company with the same force and effect as though manually affixed. I, Renee C. Llewellyn, the undersigned, Assistant Secretary, The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company do hereby certify that the original power of attorney of which the foregoing is a full, true and correct copy of the Power of Attorney executed by said Companies, is in full force and effect and has not been revoked. 'JULIN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this day ofi ufit U A4 1NSU� �vf INSU T. %NSU� �, c°Rvwyr yC� qS °Rvogar qy SUP ��RP�> yn ¢a 0 1912 n a 1919 Z 1991 n..py� y rd4 BAc"o 'b y�,y `yRMPg� yD �',p3�Nain++y'Renee C. Llewellyn, Assistant Secretary c. rn rn C U) UW �E 00 �'*- D� G E ❑ ru 3- CD Q] ra � ea) >o m� A pO N m C CO a� L) o19 LMS-12873 LMIC OCIC WAIC Multi Co_062018 SECTION 1230 CERTIFICATION OF BIDDER'S EXPERIENCE AND QUALIFICATIONS The undersigned Bidder certifies that he is, at the time of bidding, and shall be, throughout the period of the contract, licensed under the provisions of Chapter 9, Division 3, of the Business and Professions Code of the State of California, to do the type of work contemplated in the Contract Documents. Bidder shall further certify that it is skilled and regularly engaged in the general class and type of work called for in the Contract Documents. The Bidder represents that it is competent, knowledgeable, and has special skills on the nature, extent, and inherent conditions of the work to be performed. Bidder further acknowledges that there are certain peculiar and inherent conditions existent in the construction of the particular facilities, which may create, during the construction program, unusual or peculiar unsafe conditions hazardous to persons and property. Bidder expressly acknowledges that it is aware of such peculiar risks and that it has the skill and experience to foresee and to adopt protective measures to adequately and safely perform the construction work with respect to such hazards. The Bidder shall list below four (4) projects completed in the last seven (7) years of similar size and complexity that indicate the Bidder's experience as a General Contractor. 1. Project Name: Pavement Rehabilitation at 10 Locations Owner: City of San Bernardino Construction Cost: $ 2,479,000.00 Construction Time: 70 Working Days _Calendar Days Owner's Representative: Saba Engineer Owner's Telephone No.: 909) 384-5284 _ Date of Substantial Completion: June 2019 2. Project Name: 2018 Pavement Rehabilitation Owner: City of Palm Springs Construction Cost: $ 5,095,265.00 Construction Time: 110 Working Dats Calendar Days Owner's Representative. Thomas Garcia Owner's Telephone No.: 760) 322-9368 Date of Substantial Completion: April 2019 Bidders Experience & Qualifications 1230-1 3. Project Name: FARIS 2017 Resurfacing Pro-ject (1491-1740) Owner: City of Redlands Construction Cost: $ 7,588,986.00 Construction Time: 150 Calendar Days Owner's Representative:. Goutam Dobey Owner's Telephone No.: 909) 798-7584 Date of Substantial Completion: Apra 2019 4. Project Name: Park Blvd Owner: San Bernardino County Construction Cost: $ 1,272,544.00 Construction Time: 40 Working Days Calendar Days Owner's Representative: Lawrence White, Owner's Telephone No.: 909) 387-7954 Date of Substantial Completion: November 2019 Signed this 29 day of u1y , 2020. Matich Corporation Name of Bidder Signature of Bidder Robert M. Matich Printed Name of Bidder 149783 Contractor's License No. November 30, 2020 Expiration Date Vice President Title of Signatory 1000004260 DIR Reg No. Bidders Experience & Qualifications 1230-2 SECTION 1240 PROPOSED SUBCONTRACTORS Pursuant to California Public Contracting Code, Section 4100 et. seq., the following list gives the name, business address, and portion of work (description of work to be done) for each subcontractor that will be used in the work if the bidder is awarded the Contract. (Additional supporting data may be attached to this page. Each page shall be sequentially numbered and headed "Proposed Subcontractors" and shall be signed.) The Contractor shall perform, with its own organizatic to at least 50 percent of the Contract Price except th Items" may be performed by subcontract and the am Items" so performed will be deducted from the Contra( amount required to be performed by the Contractoi "Specialty Items" will be identified by the Agency i Provisions. Where an entire item is subcontracted, the will be based on the Contract Unit Price. i, Contract work amounting it any designated 'Specialty ount of any such `Specialty t Price before computing the with its own organization. the Bid or in the Special value of work subcontracted Subcontractor/Business Address/Description of Work/% of Work/License No./DIR Reg No. Pavement Recycling 10240 San Sevaine Way Systems, Inc. Jurupa Valley, CA 91752 `� Grinding L-? . 6 �y 569352 1000003363 13220 East 6th St. EBS Utilities, Inc. Corona, CA 92879 Utilities J • 5 �p 932798 1000004286 10240 San Sevaine Way, �^ Pavement Coatings Co Iurupa Valley, CA 91752 Slurry a� r� 7, 303609 1000003382 17 Commercial Ave Striping � , l� /p Cat Tracking, Inc. Riverside, CA 92507 /. 7 991122 1000011750 Rubberized Crackfiller 800 E Walnut Ave, 77b Sealant Fullerton, CA 92831 Crack Seal �' 998877 1000010726 Signature of Bidder Robert M. Matich - Vice President Name of Bidder Proposed Subcontractors 1240-1 SECTION 1250 NON -COLLUSION AFFIDAVIT TO BE EXECUTED BY BIDDER AND SUBMITTED WITH BID State of California ss. County of San Bernardino Robert M. Matich being first duly sworn, deposes and say that he or she is Vice President of Matich Corporation , the party making the foregoing bid that the bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the bid is genuine and not collusive or sham; that the bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the bidder has not in any manner, directly or indirectly sought by contract, agreement, communication, or conference with anyone to fix the bid price of the bidder or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other bidder, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true; and, further, that the bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid. Signature Matich Corporation Name of Bidder Robert M. Matich - Vice President Title July 29, 2020 Date Non -Collusion Affidavit 1250-1 SECTION 1260 DIR Project Vendor Information Vendor Information: Name: Matich Corporation Address: 1596 Harry Sheppard Blvd. City: San Bernardino ST: CA Zip: 92408 Project Manager: Jake Reade Phone: 909) 382-7400 Public Works Registration No.: Classification: Email: jreade@matichcorp.com CSLB/Certification Number: 1000004260 149783 Asbestos Boilermaker Bricklayers Carpenter Carpet/Linoleum Cement Masons X Drywall Finisher Drywall/Lathers Electricians Elevator Mechanic _Glaziers Iron Workers Laborers X Millwrights Operating Eng X Painters Pile Drivers Pipe Trades Plasterers Roofer SheetMetal Sound/Com Surveyor Teamster Tile Worker. Prevailing Wanes and Payroll: The project is subject to prevailing wage rates and enforcement by the Department of Industrial Relations (DIR). Prevailing wage rates can be obtained at: http://www.dir.ca.ciov/Public-Works/Prevailing-Wage._html. Contractors and subcontractors on most public Works projects are required to submit certified payroll records to the Labor Commissioner using DIR's electronic certified payroll reporting system. For your convenience, the link for reporting certified payroll is: litto://www.dii-.ca.QovlPublic-WorksLCertified-Payroll- Reporting.html. A copy of certified payroll, including the names and addresses of employees and/or subcontractors working on the job must be included with invoices submitted to the City of La Quinta. DIR Project Vendor Information 1260-1 tO.Qaigta - (lei u-nkNiA - ADDENDUM NUMBER TO: All Prospective Bidders and Plan Holders p JUL 2 7 20m FROM: Ubaldo Ay6n, Assistant Construction Manager PAAT'CH DATE: July 24, 2020 SUBJECT: Project No. 2020-04, Washington Street Pavement Rehabilitation The following shall be considered as incorporated into the project plans and specifications for the above referenced project. Portions of plans and specifications not specifically mentioned in this Addendum remain in force. ■ PROJECT SPECIFICATIONS Section 1210: Section 1210 is replaced; the following is a summary of the changes: • Additive Alternate 4 is changed from Sewer Air Vac Adjustment to Frontier Manhole Lowering • Additive Alternate 5 is added to include a 2" Grind and Overlay with Pavement Fabric Bid Item Section 4000: Sheet 4000-1. Section 3.0 Traffic Control, Add the following paragraph after aragraph 2• The Contractor shall maintain a 24/7 lane closure around the sewer air vac located near station 59+60 until the final paving is completed around the manhole and valve. Sheet 4000-7, Section 11.0 Asphalt Concrete and Placement of Base Material, paragraph S is replaced as follows: As Reads - Asphalt Base Course III-B2-PG 70-10 - 3" Total Thickness Finish Course III-B3-PG 70-10-RO - 2.5" Total Thickness Overlay III-B3-PG 70-10-RO - 2" Total Thickness ta Qa�tra CAI IFORKIA -- Is Amended to Read - Asphalt Base Course III-B3-PG 70-10 -Thickness Varies Finish Course/Overlay III-C2-PG 70-10 - 2" Total Thickness Sheet 4000-8, Section 11.0 Asphalt Concrete and Placement of Base Materials add the following sub -section after paragraph_ 7: Paving Fabric Paving Fabric shall be used where shown on the plans and shall conform with Section 213, "Engineering Geosynthetics". Paving fabric shall be GlasGrid, type GG8501, or approved equal. Sheet 4000-8, Section 11.0 Asphalt Concrete and Placement of Buse Material add the following sub -section after paragraph 8: 302-7 Pavement Fabric [Add the following to section 302.7.2 Placement] Paving Fabric shall be placed per the recommendations of the manufacturer and in conformance with section 302-7.2.1. Sheet 4000-10, Section 11.0 Asphalt Concrete and Placement of Base Material, add the following paragraph to sub -section 11.7 Measurement and Payment: 2" Grind and Overlay with Pavement Fabric shall be measured and paid for at the contract unit price bid per Square Foot and shall include full compensation for all labor, materials, tools, and equipment and for doing all work involved in grinding (cold -milling), excavating, loading, stockpiling, hauling, disposing of existing pavement material to the depth specified, placing asphalt concrete, furnish and installing pavement fabric per the manufacturer installation recommendations, and no additional compensation will be allowed therefore. Sheet 4000-21. Section 19.0 Adjust to Grade Sewer Force Main Air Vac, Replace entire section with the following: 19.0 LOWER FRONTIER MANHOLE (Additive Alternate 4) Lower Frontier Manhole shall include all work necessary to lower the manhole to allow for pavement grind operation. Lower Frontier Manhole shall include excavation and backfill, and lowering the manhole with a vehicle traffic rated cap. Work includes replacing damaged rings. CNLIFOKNIA Work includes all correspondence with Frontier for completion of the work and permanent tie -outs of manhole locations to the City's satisfaction so that manholes can be found in the future. The contract unit price paid for Lower Frontier Manhole shall include the per Each price to include full compensation for furnishing all labor, materials, tools, equipment, and incidentals, and for doing all the work involved in lowering the manhole, complete in place, as specified in the Standard Specifications and these special provisions, and as directed by the Engineer with no additional compensation allowed. ■ PROJECT PLANS The following changes are made to the plans: • Sheet 1,2, 3, and 5: Included construction note and detail to place raised pavement markers on median noses with paint; adjusted striping widths; and removed callout to adjust sewer force main air vac. • New Sheet for work on Calle Tampico (1 of 1): Work includes two areas for 2" grind and overlay with pavement fabric. The Contractor is hereby notified; Addendum No. 1 must be acknowledged and initialed as stipulated under the instructions to Bidders and submitted as part of the Bid. Failure to do so shall result in the City designating said bid as "Non - Responsive. " APPROVED: Dlgltally signed by Ubaldo Ayon Jr L DN: cn=Ubaldo Ayon Jr,o Clty of to Qulnta, o-Public - % Worla,email=uayan@laquintaca.gov, o-1.15 Date: 2020 0727 09:15F5-07'00' Ubaldo Ayon Assistant Construction Manager Attachments: 1. Revised Bid Schedule Dated 7-24-2020 2. Revised Plans END OF ADDENDUM NUMBER 1 ADDENDUM 01 — JULY 24, 2020 SECTION 1210 BID SCHEDULE PROJECT NO. 2020-04 WASHINGTON STREET PAVEMENT REHABILITATION City of La Quinta 78-495 Calle Tampico La Quinta, CA 92253 To Whom It May Concern: Pursuant to the Invitation to Bid, and in accordance with the provisions therein stated, the undersigned hereby proposes and agrees that on award by the City under this Bid, to execute a Contract, with necessary bonds, to furnish and install any and all labor, materials, transportation and services for Project No. 2020-04, Washington Street Pavement Rehabilitation, in accordance with the plans and specifications therefore adopted and on file with the City within the time hereinafter set forth and at the prices named in this Bid. It is understood that the basis of award shall be the lowest total price of the Base Bid Area plus All Additive Alternates. Unit prices in each and every case represent the true unit price used in preparing the bid schedule totals (Bid Form). Unit prices listed herein include material, installation and appurtenant work as is necessary to have the item complete and in place meeting the full intent of the plans and specifications. We acknowledge that unbalanced unit prices shall be sufficient cause for the rejection of our bid. Bid Schedule 1210-1 ADDENDUM 01 - JULY 24, 2020 BASE BID — WASHINGTON STREET PAVEMENT REHABILITATION Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Mobilization 1 LS $ $ 2 Traffic Control 1 LS $ $ 3 Dust Control 1 LS $ $ 4 2" Grind and Overlay 360,479 SF $ $ Continue to Full Depth Asphalt Concrete Grind 5 (3.5"f), Compact Existing 1,275 SF $ $ Aggregate Base, and 5.5" Asphalt Concrete Overlay to Bottom of Final Lift Remove and Construct 5.5" 6 AC over 6.5" AB, CLQ STD. 321 SF $ $ 195 Remove Existing Concrete 7 Sidewalk, Ramps, and 5,105 SF $ $ Cross -Gutters Remove Existing Curb and 8 Curb & Gutter (Regardless 307 LF $ $ of Height) 9 Crack Seal and Type II 11,157 ' SF $ $ SlurrySeal Construct Curb & Gutter per 10 City of La Quinta Std. Dwg. 307 LF $ $ 201and 202 (Regardless of Height Construct Sidewalk per City 11 of La Quinta Standard 240 615 SF $ $ Mod. Construct Concrete Curb 12 Ramps per City of La Quinta 9 EA $ $ Standard 250 Mod. Construct Portion of Cross- 13 Gutter per City of La Quinta 735 SF $ $ STD 230 Mod. and 231 Mod. 14 Lower and Raise Drainage 1 EA $ $ Manhole to Grade 15 Striping and All Incidentals 1 LS $ $ Total Amount of Bid Items 1 — 15 $ Bid Schedule 1210-2 ADDENDUM 01 - DULY 24, 2020 City may award all or none of the following additive alternates: ADDITIVE ALTERNATE No. 1 — Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Lower Sewer Manhole per 9 EA $ $ CVWD Standards 2 Raise Sewer Manhole per 9 EA $ $ CVWD Standards Total Amount of Bid Items 1 — 2 $ ADDITIVE ALTERNATE No. 2 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Lower Water Valve per 19 EA $ $ CVWD Standards 2 Raise Water Valve per 19 EA $ $ CVWD Standards Total Amount of Bid Items 1 — 2 $ ADDITIVE ALTERNATE No. 3 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Lower Irrigation Valve per 3 EA $ $ CVWD Standards 2 Raise Irrigation Valve per 3 EA $ $ CVWD Standards Total Amount of Bid Items 1 — 2 $ ADDTTTVE ALTERNATE No_ 4 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Lower Frontier Manhole with 1 EA $ $ Vehicle Traffic Rated Cap Total Amount of Bid Items 1 $ Bid Schedule 1210-3 ADDENDUM 01 - JULY 24, 2020 AnnTTTVE ALTERNATE Nn_ 5 - Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 2" Grind and Overlay with 504 SF $ $ Pavement Fabric Replace obliterated striping, pavement markings, and 2 pavement markers in 2" 1 LS $ $ Grind and Overlay with Pavement Fabric construction area. Total Amount of Bid Items 1 — 2 $ GRAND TOTAL BASE BID PLUS ALL ADDITIVE ALTERNATES(Figures): EJ GRAND TOTAL BASE BID PLUS ALL ADDITIVE ALTERNATES (Words): Bid Amount of each of the above Bid Items must be filled in and completed. It is understood that the quantities shown hereon are but estimates and the bidder is responsible to verify quantities prior to submitting a bid. Final payment will be based upon actual work performed, subject to such adjustments and alterations as elsewhere provided herein. Signature of Bidder (Ink) Name of Bidder (Printed or Typed) Bidder Telephone Number Bidder Email Address Bid Schedule 1210-4 3 1 � I I Q a i 44� Z g 5�3�J a W Q $o &g g coINN J °W ac a 3 okl- � a o� Inaaa i€ aaa m�4 as �5 n l= J �R Qi �w n ) 9a W W CV ��w W 3 r U w - Jill hg "v�C k n o �0 lC.OM3R] Z ~ gg 22. 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FF � W FF Fix • y Na y gg 3f1N3Atl HSf1H63JtlS S a zi Iliillil M -� gig e ug��'L—`d- ai is4 r' N �a6z t� CONTRACTORS STATE LICENSE BOARD _ ACTiVE LICENSE , .•v�r 149783 _�- CORP =--,— MATICH CORPORATION A B E�,�m 11/30/2021 www.csib.ca.gov Corporate Resolution At a meeting of the Board of Directors of MATICH CORPORATION, a California corporation duly called and held on the 29th day of May, 2020, a quorum being present, the following RESOLUTION was adopted: "Resolved, the Corporate Officers for Matich Corporation are PRESIDENT Stephen A. Matich VICE PRESIDENT & TREASURER Randall S. Valadez VICE PRESIDENT & CORPORATE SECETARY Randall S. Valadez VICE PRESIDENT - ENGINEERING Robert M. Matich FURTHER RESOLVED, that the above listed Corporate Officers are duly authorized to sign document (bids, contracts, etc.) as may be necessary on behalf of MATICH CORPORATION I, Randall S. Valadez, Secretary of MATICH CORPORATION have compared the foregoing RESOLUTION with original thereof, as it appears ion the records of the Board of Directors of said company, and do so certify that the same is true and correct transcript there from, and of the whole said original RESOLUTION. I further certify that said RESOLUTION has not been amended or revoked and is still in full force and effect. IN WITNESS THEREOF, I hereunto set my hand as such Secretary this 29th day of May, 2020. qandall S. Valadez, Se )ary Registrations Page 1 of 2 State of Califomia ! i ,irDepartment of Industrial Relations (https:.ca.govl) Contractor Information Legal Entity Name MATICH CORPORATION Corporation Active 1000004260 07/01/19 06/30/22 P O BOX 10 HIGHLAND 92346 CA United States of America 1596 E HARRY SHEPPARD BLVD SAN BERNARDINO 92408 CA United States ofAmerica rmatich@matichcorp.com MATICH CORPORATION License Number (s) CSLB:149783 Legal Entity Information Corporation Entity Number: Federal Employment Identification Number: President Name: Vice President Name: Treasurer Name: Secretary Name: CEO Name: Agency o; ti[ iVl_C C_ Agent of Service Name: Agent of Service Mailing Address: Worker's Compensation 1000004260 STEPHEN A MATICH ROBERT M MATICH RANDALL S VALADEZ RANDALL S VALADEZ STEPHEN A MATICH Back to DIR— (https://www.dir.ca.gov/) ROBERT M MATICH 1596 E HARRY SHEPPARD BLVD SAN BERNARDINO 92408 CA United States of America Do you lease employees through Professional Employer Organization (PEOP: Please provide your current worker's compensation insurance information below: PEO PEO PEO PEO InformationName Phone Email Insured by Carrier Policy Holder Name: Insurance Carrier: Policy Number: Inception date: Expiration Date: No MATICH CORPORATION OLD REPUBLIC GENERAL INSURANCE CORPORATION AICW43921513 06/25/20 06/30/21 About DIR Who we are (https://www dir.ca.gov/aboutdir.html) DIR Divisions, Boards & Commissions (https://www.dir.ca.gov/divisions_and_programs.html) Contact DIR (https://www.dir.ca.gov/Contactus.html) Work with Us Jobs at DIR (https://www.dir.ca.gov/didobs/dirjobs.htm) Licensing, registrations, certifications & permits (https://www.dir.ca.gov/permits-licenses-certifications.htmi) Required Notifications (https://www.dir.ca.gov/dosh/Required-Notifications.html) Public Records Requests (https:/Avww.dir.ca.gov/pra_request.html) Learn More Acceso al idioma (http:/Iwww.dir.ca.gov//Bilingual-Services-Acttdefault.html) Frequently Asked Questions (https://www.dir.ca.gov/fagslist.htmi) Site Map (https://www.dir.ca gov/sitemap/sitemap.html) https:Hcadir. secure.force.com/ContractorSearch/registrationSearc... 7/28/2020 Registrations Page 1 of 2 State of Califormia Department of Industrial Relations (https.! 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Contractor Information Legal Entity Name PAVEMENT RECYCLING SYSTEMS INC Corporation Active 1000003363 07/01/20 06/30/23 10240 SAN SEVAINE WAY JURUPA VALLEY 91752 CA United States of America 10240 SAN SEVAINE WAY JURUPAVALLEY 91752 CA United States ofAmerica rstewa rt@ paveme ntrecyc li ng.com PAVEMENT RECYCLING SYSTEMS INC License Number (s) CSLB:569352 CSLB:569352 Legal Entity Information Corporation Entity Number: Federal Employment Identification Number: President Name: Vice President Name: Treasurer Name: Secretary Name: CEO Name: A_Qg©Cy for Service: Agent of Service Name: Agent of Service Mailing Address: Worker's Compensation C1459029 330353433 STEPHEN CONCANNON NATHAN BEYLER STEPHEN CONCANNON Back to DIR— (https://www.dir ca govn STEPHEN CONCANNON 10240 SAN SEVAINE WAY JURUPA VALLEY 91752 CA United States of America Do you lease employees through Professional Employer Organization (PEO)?: No Please provide your current worker's compensation insurance information below: PEO PEO PEO PEOInformationName Phone Email Insured by Carrier Policy Holder Name: PAVEMENT RECYCLING SYSTEMS INC Insurance Carrier: TRAVELERS INDEMNITY COMPANY (THE) Policy Number: UB9K16850A1825K Inception date: 10/01/19 Expiration Date: 10/01/20 About DIR Who we are (https://www.dir.Ga.gov/aboutdir.htmi) DIR Divisions, Boards & Commissions (https:/Iwww.dir.Ga.gov/divisions_and_programs.html) Contact DIR (https://www.dir.ca.gov/Contactus html) Work With Us Jobs at DIR (https://www.dir.ca.gov/didobs/dirjobs.htm) Licensing, registrations, certifications & permits (https://www.dir.ca.gov/permits-licenses-certifications.html) Required Notifications (https://www.dir.ca.gov/dosh/Required-Notifications html) Public Records Requests (https://www.dir.ca.gov/pra_request.html) Learn More Acceso al idioma (http://www.dir.ca.gov//Bilingual-Services-Act/default.html) Frequently Asked Questions (https://www.dir ca.gov/faqslist html) https:Hcadir. secure.force.com/ContractorSearch/registrationSearc... 7/28/2020 Registrations Page 1 of 2 State of California k Department of Industrial Relations (https.) r: , ir.ca.gOV0 Contractor Information Legal Entity Name Corporation Active 1000004286 07101/20 06/30/21 1345 Quarry St. #101 CORONA 92879 CA United States of America 1345 Quarry St. #101 CORONA 92879 CA United States of America kfaimeather@ebsgeneral.com License Number (s) CSLB:932798 CSLB:932798 Legal Entity Information Corporation Entity Number: Federal Employment Identification Number: President Name: Vice President Name: Treasurer Name: Secretary Name: CEO Name: ApnCkfQISDryire: Agent of Service Name: Agent of Service Mailing Address: Worker's Compensation EBS UTILITIES ADJUSTING, INC 3129508 263346902 THOMAS NANCI JOSEPH D. 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BROADWAY #F SANTA ANA 92701 CA United States of America Do you lease employees through Professional Employer Organization (PEO)?: No Please provide your current worker's compensation insurance information below: PEO PEO PEO PEO InformationName Phone Email Insured by Carrier Policy Holder Name: EBS UTILITIES ADJUSTING, INC Insurance Carrier: LIBERTY MUTUAL INSURANCE COMPANY Policy Number: WC2-Z91-454286-039 Inception date: 09/28/19 Expiration Date: 09/24/20 About DIR Who we are (https://www.dir ca.gov/aboutdir html) DIR Divisions, Boards & Commissions (https://www dir.ca.gov/divisions_and_programs.html) Contact DIR (https://www.dir.ca.govIContactus.html) Work with Us Jobs at DIR (https://www dir.ca.gov/dirjobs/dirjobs.htm) Licensing, registrations, certifications & permits (https://www dir.ca.gov/permits-licenses-certifications.html) Required Notifications (https://www.dir.ca.gov/dosh/Required-Notifications.htm]) Public Records Requests (https:/ANww.dir.ca.gov/pra_request.html) Learn More Acceso al idioma (http:/twww.dir.ca.gov//Bilingual-Services-Act/default.html) Frequently Asked Questions (https://www dir.ca.gov/faqslist.html) Site Map (https://www.dir.ca.gov/sitemap/sitemap.htmi) https:Hcadir. secure.force.com/ContractorSearch/registrationSearc... 7/28/2020 Registrations Page 1 of 2 State of California Department of Industrial Relations (https'larrrlJIr.ca.govll Contractor Information Legal Entity Name PAVEMENT COATINGS CO. Corporation Active 1000003382 07/01/20 06/30/23 10240 SAN SEVAINE WAY JURUPA VALLEY 91752 CA United States of America 10240 SAN SEVAINE WAY JURUPA VALLEY 91752 CA United States of America rstewart@pavementrecycling.com PAVEMENT COATINGS CO, License Number (s) CSL6:303609 CSLB:303609 Legal Entity Information Corporation Entity Number: Federal Employment Identification Number: President Name: Vice President Name: Treasurer Name: Secretary Name: CEO Name: Agency for 5ervic@. Agent of Service Name: Agent of Service Mailing Address: Worker's Compensation C0724948 952916670 DOUGLAS FORD TIMOTHY SCHMID NATHAN BEYLER TOM MUCENSKI Back to DIR» (https://www.dir.ca.govn STEPHEN CONCANNON 10240 SAN SEVAINE WAY JURUPA VALLEY 91752 CA United States of America Do you lease employees through Professional Employer Organization (PEO)?: No Please provide your current worker's compensation insurance information below: PEO PEO PEO PEO InformationName Phone Email Insured by Carrier Policy Holder Name: PAVEMENT COATINGS CO. Insurance Carrier: TRAVELERS INDEMNITY COMPANY (THE) Policy Number: UB9K16850A1825K Inception date: 10/01/19 Expiration Date: 10/01/20 About DIR Who we are (https://www.dir.ca.gov/aboutdir.html) DIR Divisions, Boards & Commissions (https://www.dir.ca.govtdivisions_and_programs.htmi) Contact DIR (https://www.dir.ca.gov/Contactus.html) Work vrith Us Jobs at DIR (https://www.dir.ca.gov/dirjobs/dirjobs.htm) Licensing, registrations, certifications & permits (https://www.dir.ca.gov/permits-licenses-certifications.htmi) Required Notifications (https://www.dir.ca.gov/dosh/Required-Notifications.htmi) Public Records Requests (https://www.dir.Ga.gov/pra_request.html) Learn More Acceso al idioma (http://www.dir.ca gov//Bilingual-Services-Act/default.html) Frequently Asked Questions (https://www.dir.ca.gov/faqslist.html) https:Hcadir. secure.force.com/ContractorSearch/registrationSearc... 7/28/2020 Registrations Page 1 of 2 State of California Department of Industrial Relations (https:/r 10; i! 1, ir.ca.govl Contractor Information Legal Entity Name CAT TRACKING INC Corporation Active 1D00011750 07/01/20 06/30/22 17 Commercial Avenue RIVERSIDE 92507 CA United States of America 17 Commercial Avenue RIVERSIDE 92507 CA United States of America accounting@cattrackinginc.com CAT TRACKING INC License Number (s) C5113:991122 CSLB:991122 Legal Entity Information Corporation Entity Number: Federal Employment Identification Number: President Name: Vice President Name: Treasurer Name: Secretary Name: CEO Name: Qg!)n y for Service Agent of Service Name: Agent of Service Mailing Address: Worker's Compensation C3592541 463407155 PAMELA FOLLMER PAMELA FOLLMER PAMELA FOLLMER PAMELA FOLLMER PAMELA FOLLMER Back to DIR» (https://www.dir.ca gov� PAMELA FOLLMER 17 Commercial Avenue RIVERSIDE 92507 CA United States of America Do you lease employees through Professional Employer Organization (PEO)7: Please provide your current worker's compensation insurance information below: PEO PEO PEO PEO InformationName Phone Email Insured by Carrier Policy Holder Name: Insurance Carrier: Policy Number: Inception date: Expiration Date: No CAT TRACKING INC STATE COMPENSATION INSURANCE FUND 9122697-20 01/16/20 01/16/21 About DIR Who we are (https://www.dir.ca.gov/aboutdir.htmi) DIR Divisions, Boards & Commissions (https://www.dir.ca.gov/divisions_and_programs html) Contact DIR (https://www.dir.Ga.gov/Contactus.htmi) Work with Us Jobs at DIR (https://www.dir.ca.gov/dirjobs/dirjobs.htm) Licensing, registrations, certifications & permits (https://www.dir.ca.gov/permits-licenses-certifications html) Required Notifications (https://www.dir.ca.gov/dosh/Required-Notifications.html) Public Records Requests (https://www.dir.ca.gov/pra_request.htnt) Learn More Acceso al idioma (http://www.dir.ca.gov//Bilingual-Services-Act(default html) Frequently Asked Questions (https://www.dir.Ga.gov/faqslist.html) https:Hcadir. secure.force.com/ContractorSearch/registrationSearc... 7/28/2020 7/29/2020 Registrations State of California r.ca.gov/) department of Industrial Re Contractor Information Legal Entity Name RUBBERIZED CRACKFILLER SEALANT, INC. Legal Entity Type Corporation St t Registration History Effective Date Expiration Date 06/18/18 05/15/17 a us 06107/16 Active Registration Number Back to DIR>> (https://www.dir.ca.gov/�7/o6/15 1000010726 Registration effective date 07/20/20 Registration expiration date 06/30/21 Mailing Address 800 E. WALNUT AVE FULLERTON 92831 CA Unit... Physical Address 800 E. WALNUT AVE FULLERTON 92831 CA Unit... Email Address crackfill@gmail.com Trade Name/DBA RUBBERIZED CRACKFILLER SEALANT License Number (s) CSLB:998877 CSLB:998877 Legal Entity Information Corporation Entity Number: Federal Employment Identification Number: President Name: Vice President Name: Treasurer Name: Secretary Name: CEO Name: Agency for Ser'vicg Agent of Service Name: Agent of Service Mailing Address: 02/19/15 07/01/19 07/20/20 C3691002 471369260 RONALD BIEBER SHERISE BIEBER RONALD BIEBER RONALD BIEBER 06/30/19 06/30/18 06/30/17 06/30/16 06/30/15 06/30/20 06/30/21 RONALD BIEBER 18755 FAIRFAX LN HUNTINGTON BE) https://cadir.secure.force.com/ContractorSearch/registrationSearchDetails?id=a1 Rt0000003Pxs3EAC 1/3