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American Asphalt South, Inc.SECTION 1220 BID GUARANTY BOND PRINCIPAL, and Everest National 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. 2023-16 FY23/24 PAVEMENT MANAGEMENT PLAN 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 29th day of Aoril , 2024. American Asphalt South, Inc. Everest National Insurance Company Title of Signatory 7, L�� J'o S' ature of Principal Kathleen Le, Attorney -In -Fact Title of Signatory Signature of Surety 2990 Myers Street, Riverside, CA 92503 100 Everest Way, Warren Corporate Center, Warren, NJ 0705 Address Address ',�. k Note: Signatures of those executing for the surety must be properly acknowledged. Bid Guaranty Bond 1220-1 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 Riverside ) On May 7, 2024 before me, Rosa Maria Arteaga- Notary (insert name and title of the officer) personally appeared Jeff Petty , who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is subscribed to the within instrument and acknowledged to me that he executed the same in hisauthorized capacity(+es), and that by hisiherAheif 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. ;fffffflfffffpl/f'�f�f f�f f, ffw�pl f, fw!►elf f�lf/►�I/f1l�!• ..� .... f ROSA IMARIA /'V'7 � �1 f WITNESS my hand and official seal. N . �, `� COMM #2372221 .�` NOTARY PUBUC - CAUFORNIAj f SAN BERNAROINO COUNTY • My CoM.*MW EM ba AqW* 2& 2M �j]/ k �''—Signature F N w, , _( t/�✓L L/ (Seal) 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 Sacramento ) On April 29, 2024 before me, S. Smith, Notary Public (insert name and title of the officer) personally appeared Kathleen Le who proved to me on the basis of satisfactory evidence to be the person(64 whose name(e4 is/afe subscribed to the within instrument and acknowledged to me that #e/she/tk►ey executed the same in 4i9/her/tgeif authorized capacity(#e&)-, and that by 4is/her/th& signature(s) on the instrument the person(s+, or the entity upon behalf of which the person(&) 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. S. SMITH COMM. # 2442257 D WITNESS my hand and official seal.NOTARY PUBLIC CALIFORNIA COUNTY OFSACRAMENTO w Comm. Expires AN 22, W27 I Signature (Seal) h,. everest POWER OF ATTORNEY EVEREST REINSURANCE COMPANY and EVEREST NATIONAL INSURANCE COMPANY KNOW ALL PERSONS BY THESE PRESENTS: That Everest Reinsurance Company and Everest National Insurance Company, corporations of the State of Delaware ("Company") having their principal offices located at Warren Corporate Center, 100 Everest Way, Warren, New Jersey, 07059, do hereby nominate, constitute, and appoint: Elizabeth Collodi, John Hopkins, John Weber, Joseph H. Weber, Renee Ramsey, Sara Walliser, Mindy Whitehouse, Jennifer Lakmann, Deanna Quintero, Bill Rapp, Jason March, Matthew Foster, Tony Clark, Samantha Watkins, Phil Watkins, Brad Espinosa, Paula Senna, Pam Sey, Breanna Boatright, Kathleen Le, Sharon Smith, Cassandra Medina its true and lawful Attorney(s)-in-fact to make, execute, attest, seal and deliver for and on its behalf, as surety, and as its act and deed, where required, any and all bonds and undertakings in the nature thereof, for the penal sum of no one of which is in any event to exceed UNLIMITED, reserving for itself the full power of substitution and revocation. Such bonds and undertakings, when duly executed by the aforesaid Attorney(s)-in-fact shall be binding upon the Company as fully and to the same extent as if such bonds and undertakings were signed by the President and Secretary of the Company and sealed with its corporate seal. This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Board of Directors of Company ("Board") on April 21, 2016: RESOLVED, that the President, any Executive Vice President, and any Senior Vice President are hereby appointed by the Board as authorized to make, execute, seal and deliver for and on behalf of the Company, any and all bonds, undertakings, contracts or obligations in surety or co -surety with others and that the Secretary or any Assistant Secretary of the Company be and that each of them hereby is authorized to attest to the execution of any such bonds, undertakings, contracts or obligations in surety or co -surety and attach thereto the corporate seal of the Company. RESOLVED, FURTHER, that the President, any Executive Vice President, and any Senior Vice President are hereby authorized to execute powers of attorney qualifying the attorney named in the given power of attorney to execute, on behalf of the Company, bonds and undertakings in surety or co -surety with others, and that the Secretary or any Assistant Secretary of the Company be, and that each of them is hereby authorized to attest the execution of any such power of attorney, and to attach thereto the corporate seal of the Company. RESOLVED, FURTHER, that the signature of such officers named in the preceding resolutions and the corporate seal of the Company may be affixed to such powers 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 thereafter valid and binding upon the Company with respect to any bond, undertaking, contract or obligation in surety or co -surety with others to which it is attached. IN WITNESS WHEREOF, Everest Reinsurance Company and Everest National Insurance Company have caused their corporate seals to be affixed hereto, and these presents to be signed by their duly authorized officers this 101" day of October 2023. nsuran�P tea\ ins11 4,� `OpPORglle \mO LORPO 4", SEAL ',C � 2 SEAL c 1973 ' OL N 198S 3 vt QfLAWAStE..,;�Ir 03 %AWO JQ7a Everest Reinsurance Company and Everest National Insurance Company CIL--- By: Anthony Romano, Senior Vice President On this 22^d of March 2023, before me personally came Anthony Romano, known to me, who, being duly sworn, did execute the above instrument; that he knows the seal of said Company, that the seal affixed to the aforesaid instrument is such corporate seal and was affixed thereto; and that he executed said instrument by like order. LINDA ROBINS Notary Public, State of New York - No01R06239736 Qualified in Queens County Term Expires April 26, 2027 Linda Robins, Notary Public I, Sylvia Semerdjian, Assistant Secretary of Everest Reinsurance Company and Everest National Insurance Company do hereby certify that I have compared the foregoing copy of the Power of Attorney and affidavit, and the copy of the Section of the bylaws and resolutions of said Corporation as set forth in said Power of Attorney, with the ORIGINALS ON FILE IN THE HOME OFFICE OF SAID CORPORATION, and that the same are correct transcripts thereof, and of the whole of the said originals, and that the said Power of Attorney has not been revoked and is now in full force and effect. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of said Company, this 29th day of April 2024 . Sura �� n�0 �^ k 0aPOltq �.,\ C y �ptns&,. v SEAL IS t973 ` Oi (� SEAL y By: Sylvia Semerdjian, Assistant Secretary SECTION 1200 BID DATE: 5 — (.e " Zq The undersigned, as bidder, declares it has received and examined the Contract Document entitled Project No. 2023-16, FY23/24 Pavement Management Plan, 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 Attached is a bid guaranty bond as required by Paragraph 1110-15.0, BID GUARANTY. /��00 6S!l ,Z;e7 Name of Bidder 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. Name of Bidder Bidders Address ;�Y�� Contractor's License No. State of Incorporation (�i*c Sign ure of Bidder .7�— 14 Printed Na of Signatory 14kW,911 Title of Signatory Bidder's Telephone Number Bidd is Email Address 61 1 Contractor's Expiration Date W' y e-r s 6r Title of Witn Bid 1200-2 SECTION 1210 BID SCHEDULE PROJECT NO.2023-16 FY23/24 PAVEMENT MANAGEMENT PLAN 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. 2023-16, FY23/24 Pavement Management Plan, 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 BASE BID — FY23/24 PAVEMENT MANAGEMENT PLAN 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 $ 53 750"° $ 5 3 -150. 3 Crack Seal and Type II Latex 2,168,500 SF $ (�, 30 $ (o5D'5% Emulsion Aggregate Slur 4 Pavement Repair Type I: 2" Grind 19,960 SF $ 3 3d $ (os$ 00 and Asphalt Concrete Overlay Pavement Repair Type II: Edge 5 Repair AC Shoving; Grind AC Shoving 2" Below Adjacent 70 SF $ co 55 $ 3 g5O.O0 Surface and 2" Overlay' Pavement Repair Type III: 6 Remove Existing AC, Compact 370 SF ao $ 33. $ Existing Base, and Variable 12,216•01, Overlay (Depth Per Plan 7 Signing and Striping, Including All 1 LS $ �� $ po Incidentals I�iO1 Total Amount of Bid Items 1 — 7 $ , 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 to Grade 1 EA 00 $ (o�j0 o0 $ (oSQ . per CVWD Standards 2 Raise Sewer Manhole to Grade 1 EA $ 1 (05b00 $ O (9'sb.1�1 per CVWD Standards Total Amount of Additive Alternate 1 Bid Items 1 — 2 $ 32� 00 Bid Schedule 1210-2 IWO c ADDITIVE ALTERNATE NO.2 — AVENUE 60 Item Item Description Est. Unit Unit Price Item Total No. Qty. (in figures) (in figures) Dollars Dollars 1 Mobilization 1 LS $ 35, a� CO $ 35cxx� °° 2 Traffic Control 1 LS $ .27 1 d0 90 $ 27 ICY. QO Sawcut, Remove, and Dispose 3 of Existing Concrete Sidewalk, 1,490 SF $ �� ov $ o0 Ramp, and Cross -Gutter 4 Construct Sidewalk per City of 55 SF $ 3g� $ 5� Z / 17. La Quinta Standard 240 Construct Concrete Curb Ramp 5 per City of La Quinta Standard 1 EA $ �� cm $ ICI m 250, Case A 6 Crack Seal and Type II, Latex 345,470 SF $ Q 2co $ gG gZ2•Z" Emulsion Aggregate Slurry • Pavement Repair Type I: 2" 7 Grind and Asphalt Concrete 12,990 SF $ 3 30 $ Overlay Pavement Repair Type III: 8 Remove Existing AC, Compact Existing Base, and Variable 140 SF $ d0 33 $ ,� �0 to Overlay (Depth Per Plan Construct 5"-6" Asphalt 9 Concrete Over Recompacted 780 SF $ /6 5b $ 00 0� g7o• Existing Base Grade Parkway, Remove, Modify, and Replace 10 Landscape and Irrigation In 1 LS $ $ Kind to Furthest Extent Possible / to Join Proposed Curb Ram 11 Signing and Striping, Including 1 LS $ �� q $ 50 qy'�• All Incidentals Total Amount of Additive Alternate 2 Bid Items 1 —11 353 233.20 Bid Schedule 1210-3 ADDITIVE ALTERNATE NO. 3 — APPENDIX D Item Item Description Est. Unit Unit Price Item Total No. Oty. (in figures) (in figures) Dollars Dollars 1 Mobilization 1 LS $ I (:)CO. °o $ low.00 2 Traffic Control 1 LS $ � r�00 $ 2 .5CO CIO Striping and Pavement 3 Markings, Including All 1 LS $aye $ o-0 Incidentals 1 CN SM• Total Amount of Additive Alternate 3 Bid Items 1 -3 $ �29 Gam, OD GRAND TOTAL BASE BID PLUS ALL ADDITIVE ALTERNATES (Figures): $ 1, 3005j CI01 20 GRAND TOTAL BASE BID PLUS ALL ADDITIVE ALTERNATES (Words): One rM i; Il i on -fin cee..- hury-AcecL G lahku F►v e-t-hIQUScQ. ncL n t n� V1yoalrej ore- VoOcLcS and 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 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: Kri inhk M a nor d- ei andVi eL3 Owner: 1 N4o Construction Cost: Construction Time: 3S Owner's Representative: (nr-ec,, V\1rXe(-s Owner's Telephone No.: -7UD - `709 - 2232- Calendar Days Date of Substantial Completion: Noy . \ 0 4 2DZ2 Project Name: P VJ .9�-UZ Owner: o t, Of l ev-n eGy 1ct Construction Cost: $ Construction Time: 0i0 /�L Calendar Days Owner's Representative: (�,t,iCyl CaSI o Owner's Telephone No.: �t S ' lcf13" 3c�Lc5 Date of Substantial Completion: k2- 2-M?- Bidders Experience & Qualifications 1230-1 3. Project Name: Owner: e oZ3 - ZoZ`{ StaA MatnJeo4oee, Cx)n�-cLa tFA"tto Construction Cost $ 112,54 1292-, -7Z- Construction Time: Lo O Calendar Days Owner's Representative: J a B-leers Owner's Telephone No.: S Sig - &&g - (4(o2 Date of Substantial Completion: 1j off( 4. Project Name: ZgVZ , 54-r'e4 Mat4enance- Sloca, siul. Cave Sea( +C066 Owner: CAL O� e)'r1-b -Lo Construction Cost: $ I ,� 1 `-{, ��3 • ` q Construction Time: Lo O Calendar Days Owner's Representative: Ytjsen tc�L 1-oQe2 Owner's Telephone No.: 0109 - 395- ZI"7D Date of Substantial Completion: Dec - 7023 Signed this (,r day of , 2024. Name of Bidder Contractor's License No. DIR Reg No. Signat of Bidder Expiration Date �2 Printed Na of Bidder 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. Oom nw WC D9O E ,1,a &erne(4 WP �►� � 1� n �no1�s _ �onCfe�e G'rraci t r �o, Lice c03O 3(.0 IF 00000 4-199 6 a. t 9 0/0 ca, q ZW 5ueet-tor Qaveme+n�- Marbn s .I,j(. Ro, &)( In aRaurnon-�-C,4 g2223 L.1 G �fl(o30(0 00000 1g7h e��, Sign agre of Bidder Gf✓� Name of Bid er Proposed Subcontractors 1240-1 SECTION 1250 NON -COLLUSION AFFIDAVIT TO BE EXECUTED BY BIDDER AND SUBMITTED WITH BID State of California ) ss. County of ) -�/Gf , beiY'4=V'o duly :22= say that he or she is c� of 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. a46V__ Signature/ Name of BWder Title Date Non -Collusion Affidavit 1250-1 SECTION 1260 DIR Proiect Vendor Information Vendor Information: Name: ,IOer,, aW,0 Address: ,i?q,�D /7rrL'rI City: Ak-ry"ale ST: C� Zip: &-W Project Manager: �.� ✓r�'� Email: ��i`El%'EtiC4i�4��`1�Z4-1 Phone: CSLB/Certification Number: %8wlpel Public Works Registration No.: 1""'Ojr Classification: Asbestos Boilermaker Bricklayers Cement Masons Drywall Finisher Carpenter Carpet/Linoleum Drywall/Lathers Electricians Elevator Mechanic Glaziers Iron Workers LaborersMillwrights Operating Eng 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.htmi. 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: http://www.dir.ca.gov/Public-Works/Certified-Payroll-Reportin -g.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 CO 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. Vendor N%cry ame/Financial Institution (Printed) �r�� ,��/�f�� .1✓� By (Au t ize Signature) Print d Name and Title of Person Signing 721, Iran Contracting Act Certification Federal ID Number (or n/a) Date Executed 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) f Printed Name and Title of Person Signing Date Executed f 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. (b) 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. Russian Aggression Against Ukraine Compliance 1280-1