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Three Peaks Corp. BidSECTION 1200 BID DATE:-/ 6 LL2 0 2 The undersigned, as bidder, declares it has received and examined the Contract Document entitled Project No. 2022-30, COVE TRAILS PARKING LOT IMPROVEMENTS, 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 1270 Iran Contracting Act of 2010 1280 Russian Aggression Against Ukraine Sanctions 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 /01Z,�-ZV2-� Attached is a bid guaranty bond as required by Paragraph 1110-15.0, BID GUARANTY. i Name of Bidder `7 c3 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. Lip�. "7't, C' --) ---J '�- /,!� 1) Name of Bidder Bidder's Telephone Number YU Bidder's Address 2-44--s7-6 Contractor's License No. 0 State of Incorporation Bidder's Email Address / -2 /-a) r /7- .�, Contractor's Expiration Date Signature of Bidd r s ���I -Printed-Name of Signatory Title of Signatory Title of Witness Bid 1200-2 SECTION 1210 BID SCHEDULE PROJECT NO. 2022-30 COVE TRAILS PARKING LOT IMPROVEMENTS 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 2022-30, COVE TRAILS PARKING LOT IMPROVEMENTS 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. 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 SECTION 1220 BID GUARANTY BOND The Ohio Casualty Insurance * PRINCIPAL, and 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. 2022-30 COVE TRAILS PARKING LOT IMPROVEMENTS 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 3rd day of October 2023. Principal: " Three Peaks Corp. Erik Simmons, President Title of Signatory Signature of Principal P.O. Box 101, Calimesa, CA 92320 Address Surety: The Ohio Casualty Insurance Company Lawrence F. McMahon, Title of S natory Signafurk of Surety -in-Fact 790 The City Drive South, Suite 200,Orange, CA 92868 Address Note: Signatures of those executing for the surety must be properly acknowledged. Bid Guaranty Bond 1220-1 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE 1% MI-111"k1hA .H .R .P .0 .A _A .A A R .R .N .41N.iA AQ.A .A .5A -K .4r .P. .:� _VL1-: P,: ...� .vi.:va 1 - 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 Diego On DICT 0 3 2023 before me,. Maria Guise, Notary Public Date Here Insert Name and Title of the Officer personally appeared Lawrence F. McMahon 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. MARIA GUISE Commission # 2444156 ?••�� NotaryPublic- California SAN DIEGO County My Comm. Expires APR 14, 2027 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 q4jcial seal. Signature JA� Signature of Notary Public 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: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual 0 Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: Surety Company -. Number of Pages: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: ©2015 National Notary Association • www.NationalNotary.org • 1 -800 -US NOTARY (1-800-876-6827) Item #5907 (6 d) C m Liberty mutual. SURETY 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 Insurance Company The Ohio Casualty Insurance Company West American Insurance Company POWER OF ATTORNEY Certificate No: 8206895-024019 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, Christopher Conte: Dal G. Ilarshaw. CiootTi— • Shelton, Janice rvlanin; John it. Qmd111: I.mvrcncc h NlcMahori, Ldiu Dc Lucca; Minna t Iuovila; NV Itassia Kirk -Smith; 1( an Warnock; Sarah Myers; Tara Bacon all of the city of San Diego state of CA 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 8th day of December , 2021 , State of PENNSYLVANIA County of MONTGOMERY ss Liberty Mutual Insurance Company P� WSU� DIY INS& tNsu. The Ohio Casualty Insurance Company �`� poRPORar to y� rptitPAf+ar 9y SGP LU43�nRPfl'4r �� West American Insurance Company m 1912 n n 1919 f 1991 7as� ! Fpm 4 �S ACH13� a� p VAMP ,AD ifs rNUiAW' ,Ab r 07 �a 3y1 }� �'M a D� By. David M. Carey, Assistant Secretary o0 On this 8th day of December , 2021 before me personally appeared David M. Carey, who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance L ro Company, 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 a)> Iherein contained by signing on behalf of the corporations by himself as a duly authorized officer. N ft1 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. � 'rn y'Sr4`COIIIKnirvrealih of Pennsylvania - Notary Seal 41 i�4•u�y5►S' �r Teresa Pastella, Notary Public Montgomery County r. +� My commission expires March 2a, 2025By. �v canm ss on numi,er +lzeoae Teresa Pastels, NotaryPublic i�h� V hlemLer, PkMEylYrinlo Assodniion or iJciuries 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 0 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. 2 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 0 President may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, acknowledge and deliver as surety > C 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 o 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 Z L) 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 limitations 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. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this 3rd day of October , 2023 Py 1HSt1R9 X11 INS�j d 1Nsuf? ti3 coRPaq°� yC �tiy °RPO�T GP y0RPOR.,r i �o fi r; °a m 3 is sn 1912 0 n g 1919 v s 1991 ' Ely; g�`'�AcsuAL y���A'AMP°, db <�, •yorAr+� aa� Renee C. Llewellyn, Assistant Secretary LMS -12873 LMIC OCIC WAIC Multi Cc 02/21 C U C: m a CM Q o D C> V' N O N M i °O vo ro= o ro U O Q BASE BID — COVE TRAILS PARKING LOT IMPROVEMENTS Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Mobilization 1 LS $ 5, OU0 , e° $ 6,000, a� 2 Site Control 1 LS $ -zt b $ �. vow "-s 3 Dust Control 1 LS $ 5,Goa "° $ i,5, c, oV_ 4 Clearing and Grubbing/Earthwork 1 LS $coo'* $ �� 0100`'_ 5 Furnish and Install 4" Class II 857 Cy �o $ (a ( --- $ `1 do Aggregate Base r,5 Z Zl Total Amount of Bid Items 1 — 5 $ 1 k �, 2.77.!! - GRAND TOTAL BASE BID (Figures): $ , J. GRAND TOTAL BASE BID (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 Bid er (Ink) Name of Bidder (Printed or Typed) ��,' `� 7`7 � / ( c Bidder Telephone Number Bidder Email Address Bid Schedule 1210-2 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: I C (Z uJ I Owner: ( t- {r+] & Al C-0,10 rte- QM� Construction Cost: $ - �L Construction Time: © Calendar Days Owner's Representative:��.,�; I &(-_ _ _ Owner's -Telephone -No.: Date of Substantial Completion: z 2. Project Name: �-] 0 C- 0 Mc - Owner: Construction Cost: $ Construction Time: 175 Calendar Days Owner's Representative: 972-1 Imo- Owner's Telephone No.: 9 22S 15 7 0 Date of Substantial Completion: `,Li T 02- 1 Bidders Experience & Qualifications 1230-1 3. Project Name: Owner: LA C- (2 - Construction Construction Cost: $� Construction Time: (00 Calendar Days Owner's Representative: - r Owner's Telephone No.: q q f - -. Date of Substantial Completion: 4. Project Name: ! �?izL �k L l N Owner: /2--e---rc.- c� " Construction Cost: $ Construction Time: Calendar Days Owner's Representative: c Owner's Telephone No.: o of -7 1 1& 75 7 v Date of Substantial Completion: Signed this L 4 L day of �' C`t , 2023. Il E��S Com'. Name of Bidder Contractor's License No. DIR Reg No. SJgnaur of Bidd Printed Name of Bidder 1-Z- k�1 I Za'Z-�, Expiration Date -1�-e�� [)15\,-4�- Title of Signatory 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 organization, Contract work amounting to at least 50 percent of the Contract Price except that any designated "Specialty Items" may be performed by subcontract and the amount of any such "Specialty Items" so performed will be deducted from the Contract Price before computing the amount required to be performed by the Contractor with its own organization. "Specialty Items" will be identified by -the Agency in the Bid or in the Special Provisions. Where an entire item is subcontracted, the value of work subcontracted will be based on the Contract Unit Price. Subcontractor/Business Address/Description of Work/% of Work/License No./DIR Reg No. Signature of Bidder Name of Bidder Proposed Subcontractors 1240-1 SECTION 1250 ON -COLLUSION AFFIDAVIT TO BE EXECUTED BY BIDDER AND SUBMITTED WITH BID State of California j ss. County of } fE�r#�- t"Z'-7<�z7 `"�' S being first duly sworn, deposes and say that he or she is of I� 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 Name of Bidder Title Date Non -Collusion Affidavit 1250-1 CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202 '011S�ee Attached Document (Notary to cross out lines 1-6 below) ❑ See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary) Signature of Document Signer No. 1 Signature of Document Signer No. 2 (if any) A notarypublic 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�� MICHELLE k. DELAWIDER Notary Public - California Riverside County Commission X 2372833 Fxpireskug 29, 2025 Y Place Notary Seal and/or Stamp Above Subscribed and sworn to (or affirmed) before me !z� on this � day of UrDb rz , 20 L3 _ , by Date Month Year (and (2) BILI K �% NldlkOIIII Name(a) of Signeq;s) proved to me on the basis of satisfactory evidence to be the perso*) who appeared before me. OPTIONAL ■ 1 /, PO 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: Signer(s) Other Than Named Above: Number of Pages: 2 •. Mw.'. �.. ?;..., xi-,y[."Xn"Y..,�2...n .�, :. x,£ +:j;v, 7f.o5'+'A S�n,..y. �3?•.!n ,��. n: o -a In ,.r,,y,. � l'-:.� - h .�....�.s"-#:rs.��r.:.�..�.....�r.......j.:..r,. �...'�Siij?�yr„e...r.-......r...r.�:r?N;:i?�".'.�..-..C�.,•.....-.i-`Sr:�3•-.�ij%�.....`:i•�,.-.�.i[�:�:iip;its:este.{.,s.{�...;:?i;,,:S;i'�i�?:'�:'sSi;��s.�ij'r}t`i"i{-Y..i�t 02017 National Notary Association SECTION 1260 DIRProject Vendor Information Vendor Information: Address :11 17A 1 Q � City: ST: C -A - Zip: -0 Project Manager: Email: 644►1- Phone: "2-'2-Z CSLB/Certification Number: Public Works Registration No.: / C, C) 0 C e c 1't Classification: Asbestos Boilermaker Bricklayers Carpenter Carpet/Linoleum Cement Masons Drywall Finisher Drywall/Lathers Electricians Elevator Mechanic Glaziers Iron Workers Laborers X Millwrights Operating Eng Y�. Painters Pile Drivers Pipe Trades Plasterers Roofer SheetMetal Sound/Com Surveyor Teamster Tile Worker Prevailing Wages 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.gov/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: htt ://www.dir.ca. ov/Public-Works/Certified-Pa roll -Re ortin .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 SECTION 1270 COMPLIANCE WITH IRAN CONTRACTING ACT OF 2010 Pursuant to the Iran Contracting Act of 2010 (Pub. Contract Code, § 2200 et seq.), (a) Contractor shall be ineligible to bid on or submit a proposal for any contract for One Million Dollars ($1,000,000) or more if Contractor engages in investment activities in Iran as defined in Public Contract Code Section 2202.5, and/or if Contractor is identified on the list of persons engaging in investment activities in Iran prepared by the State of California pursuant to Public Contract Code Section 2203 subdivision (b). (b) For bids of One Million Dollars ($1,000,000) or more, Contractor must certify that it is not on the list of ineligible vendors prohibited from doing business with the State of California and shall complete the Iran Contracting Act Certification and submit with _their- proposal at the time of bid. Contractor shall obtain the Iran Contracting Act Certification in the form approved by the State of California, or upon written request to the City Clerk's Office, a copy of the form will be provided to Contractor. Failure by Contractor to provide the certification required by this Section may deem Contractor's bid non-responsive. (c) Nothing in this -Section is intended to prevent the City from exercising its rights pursuant to Public Contract Code section 2203, subdivision (c) or (d), or both, on a case-by-case basis. Iran Contracting Act Certification 1270-1 IRAN CONTRACTING ACT CERTIFICATION Pursuant to the Iran Contract Act of 2010 (Public Contract Code 2200-2208), Vendors/Bidders are ineligible to bid on or submit a proposal for any contract with a public entity for goods or services of one million dollars ($1,000,000) or more if the Vendor/Bidder engages in investment activities in Iran. MUST BE SUBMITTED WITH BID PROPOSAL IF BID AMOUNT IS $1,000,000 OR MORE Prior to bidding on, submitting a proposal, or executing a contract or renewal for a public entity contract for goods or services of $1,000,000 or more, a vendor must either: a) certify it is not on the current list of persons engaged in investment activities in Iran created by the California Department of General Services ("DGS") pursuant to Public Contract Code -section 2203(b) and is not a financial institution extending $20,000,000 or more in credit to another -person, for 45 days or more, if that other person will use the credit to provide goods or services in the energy sector in Iran and is identified on the current list of persons engaged in investment activities in Iran created by DGS; or b) demonstrate it has been exempted from the certification requirement for that solicitation or contract pursuant to Public Contract Code section 2203(c) or (d). To comply with this requirement, please insert your vendor or financial institution name and Federal ID Number (if available) and complete one of the options below. Please note: California law establishes penalties for providing false certifications, including civil penalties equal to the greater of $250,000 or twice the amount of the contract for which the false certification .was made, contract termination, and three-year ineligibility to bid on contracts. (Pub. Cont. Code § 2205.) OPTION #1 - CERTIFICATION I, the official named below, certify I am duly authorized to execute this certification on behalf of the vendor/financial -institution identified below, and the vendor/financial institution -identified-below -is-not-on the current list of persons engaged in investment activities in Iran created by DGS and is not a financial institution extending twenty million dollars ($20,000,000) or more in credit to another person/vendor, for 45 days or more, if that other person/vendor will use the credit to provide goods or services in the energy sector in Iran and is identified on the current list of persons engaged in investment activities in Iran created by DGS. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. By Name/Financial Institution (Printed) 4,.K --e r'r-�cs �'c-!7 pName and 1t1 9r- Person Signing \ Iran Contracting Act Certification Federal 1D Number (or nIa) 2-7 - !-�7 [v4a3 Date E ecuted /U -2 1270-2 OPTION #2 — EXEMPTION Pursuant to Public Contract Code sections 2203(c) and (d), a public entity may permit a vendor/financial institution engaged in investment activities in Iran, on a case- by-case basis, to be eligible for, or to bid on, submit a proposal for, or enters into or renews, a contract for goods and services. If you have obtained an exemption from the certification requirement under the Iran Contracting Act, please fill out the information below, and attach documentation demonstrating the exemption approval. Vendor Name/Financial Institution (Printed) Federal ID Number (or n/a) By (Authorized Signature) Printed Name and Title- of Person Signing Date Executed Iran Contracting Act Certification 1270-3 SECTION 1280 COMPLIANCE WITH CALIFORNIA EXECUTIVE ORDER N-6-22 RUSSIAN AGGRESSION AGAINST UKRAINE (a) Contractor shall comply with California Governor Executive Order N-6-22 regarding sanctions in response to Russian aggression in the Country of Ukraine, and any implementing guidelines and/or economic sanctions imposed by the United States government in response to Russian actions in Ukraine, as well as any sanctions imposed under California law (collectively "economic sanctions"). Contractor shall comply with all such economic sanctions. By submitting a bid to the City, Contractor agrees to take any and all actions to support the Ukrainian government and people as required by law, including by refraining from new investments in, and financial transactions with, Russian institutions or companies that are headquartered or have their principal place of business in Russia (Russian entities), not transferring technology to Russia or Russian entities, and directly providing support to the government and people of Ukraine. (h) If bidding on a contract for Five Million Dollars ($5,000,000) or more, Contractor shall submit a written report to the City on Contractor's compliance with the economic sanctions, and the steps Contractor has taken in response to Russia's actions in Ukraine, including, but not limited to, desisting from making new investments in, or engaging in financial transactions with, Russian entities, not transferring technology to- Russia or Russian entities, -and directly providing support to the government and people of Ukraine as required by law. Failure to submit the report required by this Section may deem Contractor's bid non-responsive. Please include a written report to the City if this section is applicable.