SAVI Construction Inc.
April 2, 2025
SAVI Construction Inc.
6725 Birmingham Dr.
Chino, CA 91710
SUBJECT: BID BOND RELEASE – PROJECT NO. 2024-05 CITYWIDE MISCELLANEOUS
ADA IMPROVEMENTS
To Whom It May Concern:
Thank you for submitting your proposal for the above referenced project. The La Quinta City
Council, at its regular meeting of April 1, 2025, awarded the contract to the lowest responsive
bidder, CT&T Concrete Paving Inc.
The above-mentioned original Bid Bond, which accompanied your proposal, is enclosed. Your
interest in working with the City of La Quinta is greatly appreciated, and we hope that you will
accept future opportunities to bid on other city projects.
Sincerely,
Olivia Rodriguez, Acting Deputy City Clerk
City Clerk’s Office
Enclosure
c: Developers Surety and Indemnity Company
File
SECTION 1200
BID
DATE: 03/21 /2025
The undersigned, as bidder, declares it has received and examined the Contract
Document entitled Project No. 2024-05 and CDBG Project No. 4.LQ.50-24, Citywide
Miscellaneous ADA 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
1290 B-4 Certification of Bidder Regarding Non -Segregated Facilities (Required for all
Projects)
1290 B-7 Bidder's Certification on Federal Contract Requirements (Required for all
Projects)
1290 B-8 Questionnaire Regarding Bidders (Required for all Projects)
1290 B-9 List of Subcontractors and Suppliers (Required for all Projects)
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
03/21 /2025
Initials
NP
Bid 1200-1
SECTION 1210
BID SCHEDULE
PROJECT NO. 2024-05 AND CDBG PROJECT NO. 4.LQ.50-24
CITYWIDE MISCELLANEOUS ADA 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 Project No. 2024-05 and CDBG Project No.
4.LQ.50-24, Citywide Miscellaneous ADA 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 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 — CITYWIDE MISC. ADA IMPROVEMENTS — NAVARRO PLAZA
Item
Item Description
Est.
Unit
Unit Price
Item Total
No.
Qty.
(in figures)
(in figures)
Dollars
Dollars
1
Mobilization
1
LS
$ 3 Od O
$ 3 00 0
2
Traffic Control
1
LS
$ 2 S fl a
$ 2S;'V D
3
Dust Control
1
LS
$
$ aS' a 0
4
Earthwork
1
EA
$ 6000
$ E, O O U
5
Sawcut, Remove, and Dispose of
20
LF
$ 3
$ 6 O
ExistingCurb
6
Sawcut, Remove, and Dispose of
855
SF
$ g
$ 6 �[� p
ExistingSidewalk and Ram
7
Construct Sidewalk per City of La
845
SF
$ I $
$ l5�2 I D
Quinta Std. No. 240 Mod.
Construct Concrete Curb Ramp per
8
City of La Quinta Std. No. 250 Mod.
1
EA
$ 4500
4-5 f7 $ 0
per Plan, Case B (Including Curb
along Ram
Full Depth Grind Asphalt Concrete
9
Pavement (Y), Compact Existing
35
SF
$ 5-0
$ ( *4 SD
Base, and Variable Overlay (Y —
4"
Grade Parkway, Remove, Modify,
10
and Replace Landscape,
1
LS
$ 3500
$ 3S 0 O
Hardscape, and Irrigation in Kind to
Furthest Extent Possible
11
Signing and Striping, Including All
1
LS
$ 0
$ 2SrO O
Incidentals
Total Amount of Bid Items 1 —11
$ 42, 100
Bid Schedule 1210-2
City may award all or none of the following additive alternates:
ADDITIVE ALTERNATE NO. 1 — AVENIDA LA FONDA SPEED TABLES
Item
Item Description
Est.
Unit
Unit Price
Item Total
No.
Qty.
(in figures)
(in figures)
Dollars
Dollars
1
Mobilization
1
LS
$ (00 0 0
$ 6 p 0 0
2
Traffic Control
1
LS
$ R S 0 0
$ &_5-Da
3
Dust Control
1
LS
$ 4 00 0
$ 4000
4
Sawcut, Remove, and Dispose of
90
LF
30
$ aq D O
Existing$ Curb; and/or Curb & Gutter
5
Sawcut, Remove, and Dispose of
785
SF
$ (� 5" Q
$ 51 D Z •S 0
ExistingRam and Pavers
6
Construct Sidewalk per City of La
450
SF
$ 2 2-
$ 016700
Quinta Std. No. 240 Mod.
Remove and Dispose of Existing
7
Roadway Section to Depth
750
SF
$ 6.5 p
$ 4
Required
8
Construct 5.5" Asphalt Concrete
460
SF
$ 3 5�
$ 16, (0 0
over 6.5" Aggregate Base
Construct Two (2) Concrete Speed
9
Tables (Including All Concrete
1
LS
$ 12 0 D
$ 12,100
Work, Aggregate Base, Grading,
Rebar, and Conduit
Furnish and Install Truncated Dome
10
Concrete Tile per City of La Quinta
75
SF
$ (.� • SO
$ 3 561 • s
Std. 250 Mod.
Remove, Regrade, and Reset
11
Sidewalk Pavers Per City of La
275
SF
$ 2�-b
$ Sd p
Quinta Std. 206
Salvage to City Existing Pull Box
12
and Furnish and Install New No. 6
1
EA
$ 0 O
5
$ L 5�0 a
Pull Box per Caltrans Std. Plan ES-
8A
Grade Parkway, Remove, Modify,
13
and Replace Landscape,
1
LS
$ S b 0
$ P S a o
Hardscape, and Irrigation in Kind to
Furthest Extent Possible
14
Signing and Striping, Including All
1
LS
$ g S D 0
$ 9,5-0 0
Incidentals
Total Amount of Additive Alternate Bid Items 1 —14
$ --Z` O
Bid Schedule 1210-3
GRAND TOTAL BASE BID PLUS ALL ADDITIVE ALTERNATES (Figures):
$ c 39,640- 00
GRAND TOTAL BASE BID PLUS ALL ADDITIVE ALTERNATES (Words):
One kur,4reel -"V1i�4m tAW 4kOuSaHl Six kuhdY-d1
t 1"tA 0 h
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.
4I V `!'d,J!-'2' f/ -
Signature of Bidder (Ink)
Ramesh Bachuvala
Name of Bidder (Printed or Typed)
(805) 889-3547
Bidder Telephone Number
contactsavi247@gmail.com
Bidder Email Address
Bid Schedule 1210-4
Attached is a bid guaranty bond as required by Paragraph 1110-15.0, BID GUARANTY.
Ramesh Bachuvala
Name of Bidder
(805) 889-3547
Bidder's Telephone Number
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.
Ramesh Bachuvala
Name of Bidder
6725 Birmingham Dr, Chino, CA 91710
Bidder's Address
1116157
Contractor's License No.
California
State of Incorporation
f"qhA .�
Signature of Bidder
Ramesh Bachuvala
Printed Name of Signatory
President
Title of Signatory
(805) 889-3547
Bidder's Telephone Number
contactsavi247@gmail.com
Bidder's Email Address
04/30/2026
Contractor's Expiration Date
Witness MITI I, PArEL
Title of Witness
Bid 1200-2
SECTION 1220
BID GUARANTY BOND
PRINCIPAL, and Developers Surety and Indemnity 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. 2024-05 AND CDBG PROJECT NO. 4.LQ.50-24
CITYWIDE MISCELLANEOUS ADA 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 17th day of
March , 2025.
SAVI Construction Inc.
Title of Signatory = e
=c SE2 i
. ••Ce ee
Signature of Principal
,,'ear"a
6725 Birmingham Dr., Chino, CA 91710
Address
Developers Surety and Indemnity Company
Attorney -in -Fact
Title of Signatory
Signature of S e Edward N. Hackett, Attorney -in -Fact
800 Superior Avenue E., 21st Floor, Cleveland, OH 44114
Address
Note: Signatures of those executing for the surety must be properly acknowledged.
Bid Guaranty Bond 1220-1
CALIFORNIA 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 0 11 L
On MAR 17 2025
before me, CsAr(y P. H"ock,r013tan., Pw6ki c
(here insert name and title of e officer)
personally appeared fd ,.) e,r-d 0 . }J eA (�{}
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.
Signature r-anj,4
CARLY P. MATLOCK
0— COMM. #2423661 z
X _ . Notary Public - California A
Z a Orange County o
My Comm. Expires Oct. 27, 2026
(Seal)
Optional Information
Although the information in this section is not required by law, it could prevent fraudulent removal and reattachment of this acknowledgment to an
unauthorized document and may prove useful to persons relying on the attached document.
Description of Attached Document
The preceding Certificate of Acknowledgment is attached to a document
titled/for the purpose of SAV ) ConShuciion . Inc.
containing -,t pages, and dated MAR 17 2025
The signer(s) capacity or authority is/are as:
❑ Individual(s)
Attorney -in -Fact
❑ Corporate Officer(s)
❑ Guardian/Conservator
❑ Partner - Limited/General
❑ Trustee(s)
❑ Other:
representing:
Title(s)
Name(s) of Person(s) or Entity(les) Signer is Representing
Method of Signer Identification
Proved to me on the basis of satisfactory evidence:
Q form(s) of identification O credible witness(es)
Notarial event is detailed in notary journal on:
Page # Entry #
Notary contact:_
I Other
❑ Additional Signer(s)
1771
❑ Signer(s)Thumbprint(s)
0 Copyright 2007-2021 Notary Rotary, PO Box 41400, Des Moines, IA 50311-0507. All Rights Reserved. Item Number 101772. Please contact your Authorized Reseller to purchase copies of this form.
POWER OF ATTORNEY FOR
COREPOINTE INSURANCE COMPANY
DEVELOPERS SURETY AND INDEMNITY COMPANY
59 Maiden Lane. 43rd Floor, New York, NY 10038
(212)220-7120
KNOW ALL BY THESE PRESENTS that, except as expressly limited herein. COREPOINI'E INSURANCE: COMPANY and DI-VI'LOPLRS SURF.I'Y AND
INDEMNITY COMPANY, do hereby make, constitute and appoint
Brendan Hackett and Edward Hackett
, of Laguna Beach, CA
as its true and lawful Attorney -in -Fact, to make, execute, deliver and acknowledge, for and on behalf of said companies, as sureties, bonds, undertakings and contracts
of suretyship giving and granting unto said Attomey-m-Fact full poser and authority to do and to perform every act necessary_ requisite or proper to be done in
connection therewith as each of said company could do, but reserving to each of said company hill power of substitution and revocation, and all of the acts of said
Attomey-in-Fact, pursuant to these presents, are hereb) ratified and confirmed I'his Power of Attorney is eflecti%e September 20, 2024 and
shall expire on December 31, 2025
This Power of Attorney is granted and is signed under and by authority ofthe following resolutions adopted by the Board of Directors ol'COREPOINTE INSURANCL•
COMPANY and DEVELOPERS SURETY AND INDEMNITY COMPANY (collectively, "Company") on February 10, 2023.
RHSOI-VI'.D, that Sam Zaza_ President. Surety Underwriting, James Bell. Vice President, Surety Underwriting, and Craig Dawson, Executive Underwriter.
Surety. each an emplo) ee of Am (rust North America. Inc., an affiliate of the Company (the "Authorized Signors"). are hereby authorized to execute a Powcr
of Auorne). qualifying attorney(s)-in-tact named in the Power of Attorney to execute, on behalf of the Company, bonds, undertakings and contracts of
suretyship, or other suretyship obligations-. and that the Secretary or any Assistant Secretary of the Company be. and each of them hereby is, authorized to attest
the execution ofany such Power of Attorney.
RESOLVED, that the signature ofany one of the Authorized Signors and the Secretary or any Assistant Secretary of the Company, and the seal ofthe Compan)
must be affixed to any such Povcr of Attorney, and an} such signature or seal may be affixed by facsimile, and such Power of Attomey shall be salad and
binding upon the Company %%hen so allixed and in the fnlUre with respect to any bond, undertaking or contract of suretyship to which it is attached.
IN WITNESS WHEREOF, COREPOINTE INSURANCE COMPANY and DLVELOPERS SIIRF.IY AND INDEMNITY COMPANY have causeed these presents to be
signed by the Authorized Signor and attested by their Secretary or Assistant Secretary this March 27, 2023
,,�44 �44 �, °s°r°rrrrr�ri
By: / ��NSURgtiC,°; �� AND
Printed Na c Sam 7aza — •G •• C) _ 69 �� Fp ,• 2
Title: President, Surety Underwriting
ACKNOWLEDGEMENT:
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 COUN1YOF Orange
SEAL:
.�AWP�• •moo
a 1936 �-
O]J,� Cq(lFOR�I
On this 27 day of March , 20 23 , before Inc. -Hoang-Queen Phu Pham . personally appeared Sam Zaza
who proved to me on the basis of satisfactory evidence to be the person sshose name is subscribed to within the instrument and acknowledged to me that they executed
the same in their authorized capacity_ and that by the signature on the instrument the entities upon behalf which the person acted. executed this instrument.
1 certify. under penalty of perjury. tinder the lases of the State of California that the foregoing paragraph is true and correct
WITNESS my hand and official seal IF
HOAN&QUYEN P. ►HAM
Notary Public - California
Signature JLLv - _ Commission ange County
ission # 2432970
My Comm. Expires Dec 37, 202i
CORPORATE CERTIFICATION
flu undersigned. the Secretary or Assistant Secretary of CORI-POIN]I: INSURANCE COMPANY and DNVELOPI:RS SIJR1 IY AND INDL•MNIIY
COMPANY, does hereby certify that the provisions of -the resolutions of the respective Boards of Directors of said corporations set forth in this Posner of Attorney
are in force as of the date of this Certification
'Iles Certification is executed in the City of Cleveland. Ohio. this March 19. 2023.
DocuSigned by:
6B6415UADE548C
Barry W Moses, Assistant Secretary
DocuSignEnvelopelD:3352BFD6-5E9D-4796-837E-C1 E455E6530F
POA No. N/A
Ed 0323
Signed and sealed this 17th day of March, 2025
No. 4606-0
STATE OF CALIFORNIA
DEPARTMENT OF INSURANCE
SAN FRANCISCO
Amended
Certificate of Authority
THIS IS TO CERTIFY that, pursuant to the Insurance Code of the State of California,
Developers Surety and Indemnity Company
of California, organized under the laws of California, subject to its Articles of Incorporation or other
fundamental organizational documents, is hereby authorized to transact within this State, subject to all
provisions of this Certificate, the following classes of insurance:
Fire, Marine, Surety, Disability, Plate Glass, Liability, Workers' Compensation,
Common Carrier Liability, Boiler and Machinery, Burglary, Credit,
Sprinkler, Team and Vehicle, Automobile, Aircraft, Legal, and Miscellaneous
as such classes are now or may hereafter be defined in the Insurance Laws of the State of California.
THIS CERTIFICATE is expressly conditioned upon the holder hereof now and hereafter being in
full compliance with all, and not in violation of any, of the applicable laws and lawful requirements made
under authority of the laws of the State of California as long as such laws or requirements are in effect and
applicable, and as such laws and requirements now are, or may hereafter be changed or amended.
IN WITNESS WHEREOF, effective as of the 1'r day of November,
2017,1 have set my hand and caused my official seal to be aff xed this
1" day of November, 2017.
Dave Jones
Insurance Commissioner
By Valerie Sarfaty
for Joel Laucher
Chief Deputy
NOTICE:
Qualification with the Secretary of State must be accomplished as required by the California Corporations Code promptly after
issuance of this Certificate of Authority. Failure to do so will be a violation of Insurance Code section 701 and will be grounds for
revoking this Certificate of Authority pursuant to the covenants made in the application therefor and the conditions contained
herein.
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
. -. ^. - -..�-r.,rr.�-,r-c-.s-��,��c,Fr..�c,�c�r�- - - . --. . --- ��r•:cr,�,�..,E.c,�c,�s�.r,�r.�<z~,r_.crcc>.c�,�,�,�c.�c,�,�
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
On MMW 20. Q025 before me,
Date
Here Insert Name and Title of the Officer
personally appeared - Rami-sa A CH uyA LA
Name() of Signer()
who proved to me on the basis of satisfactory evidence to be the person() whose name() is/are-
subscribed to the within instrument and acknowledged to me that he/s# @Ahey executed the same in
his/weir authorized capacity(iee), and that by his/49W41;oii` signature() on the instrument the person(),
or the entity upon behalf of which the person() acted, executed the inttrument.
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.
Signature U?llbAiC
PRITI B PATEL
Notary Public - California Signature of Notary Public
s Riverside County
Commission d 2352663
My Comm. Ex9iresApr 17, 2C25
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
goob
Title or Type of Document: aC7(OxJ �220 AlGUARAWf ' Document Date:
Number of Pages: Signer(s) Other Than Named A ove: WE
Capacity(ies) Claimed by Signers)
Signer's Name: U lA
❑ Corporate Officer — Title(s): ES
Partner — n Limited ❑ General
❑ Individual ❑ Attorney in Fact
17 Trustee ❑ Guardian or Conservator
Other:
Signer Is Representing:
Signer's Name:
❑ Corporate Officer — Title(s):
LJ Partner — ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
02014 National Notary Association • www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907
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.
Project Name:
ZONE 2 Curb Ramps Project
Owner: City of Huntington Beach
Construction Cost: $ $212,000
Construction Time: Jan 2025
Owner's Representative:
Max Olin
Calendar Days 20
Owner's Telephone No.: Office: (714) 536-5518
Date of Substantial Completion:
2. Project Name:
Feb 2025
*Sewer Main lining and Replacement & Street Rehabilitation
Owner: City of South Gate
Construction Cost: $ $1,600,000
Construction Time: Present Calendar Days Present
Owner's Representative: Charles D. Herbertson, P.E.
Owner's Telephone No.:
P: (323) 357-9614
Date of Substantial Completion:
*1 have served as the primary point of contact for this project, overseeing its design,
project management, and bid process.
Bidders Experience & Qualifications 1230-1
3. Project Name: *Various Projects related to Street Imp., and Grading
4.
Owner: LEE+RO - Various project within Orange, Los Angeles and Riverside County
Construction Cost: $ >$500,000
Construction Time: Present
Owner's Representative: Murthy Kadiyala, PE, PLS
Owner's Telephone No.: (951) 207-2956
Calendar Days Present
Date of Substantial Completion:
*1 have served as the primary point of contact for this project, overseeing its design, project
management, bid process, and acting as the construction manager
Project Name:
Owner:
Construction Cost: $
Construction Time:
See attached
Owner's Representative:
Owner's Telephone No.:
Date of Substantial Completion:
Calendar Days
Signed this o25'"' day of MQg1(� , 2025.
Ramesh Bachuvala
Name of Bidder
Signature of Bidder
Ramesh Bachuvala
Printed Name of Bidder
1116157
Contractor's License No
2000001284
DIR Reg No.
04/30/2026 & 06/30/2025
Expiration Date
President
Title of Signatory
Bidders Experience & Qualifications 1230-2
City of La Quinta
Project No. 2024-05 and CDBG Project No. 4.LQ.50-24,
Citywide Miscellaneous ADA Improvements
STATEMENT OF QUALIFICATIONS
SAVI Construction Inc.
Company Overview
SAVI Construction Inc. is a licensed and insured construction firm specializing in public works projects. We
are committed to delivering high -quality infrastructure improvements while maintaining compliance with all
municipal, state, and federal regulations. Our team has extensive experience managing and executing
projects that enhance accessibility and public safety.
Relevant Experience
Although SAVI Construction Inc. is a relatively new entity, our leadership has extensive experience in public
works construction and project management. Our principal has successfully managed and overseen
numerous public infrastructure projects over an 18-year career in construction project management. These
projects include ADA ramps, sidewalks, curb and gutter improvements, road rehabilitation, and various other
municipal infrastructure upgrades.
Completed Projects
• City of Huntington Beach — Public Works Infrastructure Project
o Scope: Concrete improvements, ADA-compliant curb ramps, and sidewalk construction.
o Responsibilities: Project management, compliance with public agency requirements,
coordination with inspectors, and quality control.
Key Qualifications
• 18 Years of Public Works Experience: Extensive background in managing construction projects for
municipal agencies, ensuring compliance with prevailing wage laws, safety regulations, and public
contracting requirements.
• Project Management Expertise: Skilled in budgeting, scheduling, subcontractor coordination, and
risk management to ensure timely and efficient project delivery.
• ADA Compliance Knowledge: Strong understanding of ADA requirements and best practices for
accessibility improvements.
• Familiarity with Public Works Standards: Experience working with public agencies, engineers, and
inspectors to meet design and construction specifications.
Capability Statement
SAVI Construction Inc. has the capability, resources, and expertise to successfully complete the City of La
Quinta Project No. 2024-05 and CDBG Project No. 41Q.50-24, Citywide miscellaneous ADA Improvements,
Project. Our extensive experience in managing public works projects ensures that we can effectively oversee
the construction, coordinate with stakeholders, and deliver a high -quality outcome that meets all project
requirements. We look forward to the opportunity to bring our expertise and dedication to this project.
Thank you for your consideration.
Page 1 of 3
City of La Quinta
Project No. 2024-05 and CDBG Project No. 4.LQ.50-24,
Citywide Miscellaneous ADA Improvements
Qualifications and Experience
Ramesh Bachuvala, EIT, Class A (1116157) — President/Project Manager
Ramesh Bachuvala is an aspiring Engineer -in -Training with more than 18 years of experience in planning,
designing, and constructing Public Works Projects such as Street improvements, Grading, storm drains,
sewers, and other site preparation work. He is a Results -driven Public Works Construction Project Manager
with extensive experience in overseeing complex infrastructure projects, including roads, and municipal
facilities. Expertise in project planning, budgeting, and scheduling, with a strong focus on ensuring
compliance with safety regulations and quality standards. Proven ability to lead cross -functional teams,
manage stakeholder expectations, and navigate regulatory requirements. Skilled in optimizing resource
allocation and mitigating risks to deliver projects on time and within budget, contributing to the successful
development of community infrastructure. Ramesh has extensive experience in the preparation of traffic
control plans for pipeline construction and street improvements within the public right-of-way. Areas of his
expertise include - Utility Search and Coordination with Utility Companies; Hydraulic and Hydrology Analysis;
WQMP/ SWPPP Reports; Traffic Control Design; and ROW and Easement Analysis and Coordination.
• Licensing: Class A General Engineering License (1116157).
• Experience:18 Years of experience in the Civil Engineering industry as a Project Manager/
Construction Manager of experience working with municipal and government agencies within San
Bernardino, Riverside, Los Angeles, and Orange Counties.
• Team: Our team includes skilled laborers, a Construction Manager, and safety officers with an
understanding of OSHA standards and concrete repair techniques.
• Equipment: We maintain a fleet of modern equipment and tools necessary for efficient and precise
concrete maintenance.
MURTHY KADIYALA, PE, PLS (On call Engineer
With 19 years of experience in a variety of projects in Municipal Water and Wastewater System Planning,
Design, and Construction Management, Murthy has helped find solutions to many design challenges in his
career. Murthy has provided engineering and construction support services for many Street improvement
projects, Water and Wastewater pipeline installations, and rehabilitation projects and helped close them out
successfully. His added knowledge of the service connections to private developments including land title
and encumbrances has enabled him to identify all required facilities and potential issues early in the design
process. His Land Surveying experience helps add a different perspective to projects.
Juan - Foreman
Juan with over 20 years of expertise in public works with a proven track record in managing and executing
large-scale infrastructure projects, including roads, bridges, and municipal buildings. Skilled in supervising
construction teams, Adept at optimizing workflows, managing materials and equipment, and maintaining
strict adherence to timelines and regulations. Committed to delivering high -quality results and enhancing
community infrastructure through effective leadership and project management.
Page 2 of 3
References
City of Huntington Beach
Max Olin
Capital Project Administrator
Public Works Department
Office: (714) 536-5518
Email:max.olin@surfcity-hb.org
City of Huntington Beach
John Griffin
City Inspector
Public Works Department
Cell: (714) S01-S646
Email:jgriffin@surfcity-hb.org
Charles D. Herbertson, P.E., L.S.
Consulting Civil Engineer
City of South Gate / Public Works Department
8650 California Avenue, South Gate, CA 90280
P: (323) 357-9614
Email: cherbertson@sogate.org
W: cityofsouthgate.org
Murthy Kadiyala, PE, PLS
Civil Engineer
Los Angeles + Orange County
1199 South Fullerton Road
City of Industry, CA 91748
Email: murthy.kadiyala@lee-ro.com
Cell: (951)207-2956
City of La Quinta
Project No. 2024-05 and CDBG Project No. 4.LQ.50-24,
Citywide Miscellaneous ADA Improvements
Page 3 of 3
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.
Dan Francis, Competitive Asphalt Coatings, Inc.
P.O. Box 680, Highland, CA 92346
Asphalt and Striping
11%
CA LIC # 739926 & DIR 1000012993
gamj�� ,-
Signof Bidder
D awm,e—S� 6 0.f�nuVc�
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 So, , &tfr-A d i no )
Rary-�ts^ C3atJkL&VA-C'M_- , being first duly sworn, deposes and say that he
or sbe-is of S AV E C.ov-5-iuein'a►-, ly, c 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.
Taw"et'-
Signature
Ramesh Bachuvala
Name of Bidder
President
Title
,�It-d aWr
Date
Non -Collusion Affidavit 1250-1
SECTION 1260
DIR Project Vendor Information
Vendor Information:
Name: SAVI Construction Inc.
Address: 6725 Birmingham Dr
Zip: 91710
Project Manager:
Ramesh Bachuvala
City:
Chino ST: CA
Email: contactsavi247@gmail.com
Phone: (805) 889-3547 CSLB/Certification Number:
Public Works Registration No.:
Classification:
2000001284
1116157
Asbestos Boilermaker Bricklayers Carpenter Carpet/Linoleum
Cement Masons X Drywall Finisher Drywall/Lathers Electricians
Elevator Mechanic Glaziers Iron Workers Laborers Millwrights
Operating Eng 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.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:
http://www.dir.ca.gov/Public-Works/Certified-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
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 Name/Financial Institution (Printed) Federal ID Number (or n/a)
SAVI Construction Inc. 99-1544486
By (Authorized Signature) ,h
Printed Name and Title of Person Signing Date ec d
Ramesh Bachuvala - President n4l ng _9h )r-,
Iran Contracting Act Certification 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
Printed Name and Title of Person Signing I Date Executed
Iran Contracting Act Certification 1 270_3
Exhibit B-4
Required Bid Form
CERTIFICATION OF BIDDER
REGARDING NONSEGREGATED FACILITIES
Project Name: CITYWIDE MISCELLANEOUS ADA IMPROVEMENTS CITY PROJECT NO. 2024-05 & CDBG PROJECT NO. 41Q.50-24
Name of Bidder: Ramesh Bachuvala
The above named Bidder hereby certifies that:
do not maintain or provide for my employees any segregated facilities at
any of my establishments, and that I do not permit my employees to perform
their services at any location, under my control, where segregated facilities
are maintained. As used in this certification, the term "segregated facilities"
means any waiting rooms, work areas, rest rooms, wash rooms, restaurants
and other eating areas, time clocks, locker rooms or other dressing areas,
parking lots, drinking fountains, recreation or entertainment areas,
transportation, and housing facilities provided for employees which are
segregated by explicit directive or are in fact segregated on the basis of race,
color, religion, national origin, or because of habits, local customs, or
otherwise.
I further agree to obtain identical certifications from all proposed
subcontractors prior to the award of subcontracts exceeding $10,000.
Signature: InAd, L
Name (Print):
Ramesh Bachuvala
Title: President
Date: - Nw
CDBG Required Bid Form 1290-1
Exhibit B-7
Required Bid Form
BIDDER CERTIFICATION ON
FEDERAL CONTRACT REQUIREMENTS
CITYWIDE MISCELLANEOUS ADA
Project Name: IMPROVEMENTS Bid/Solicitation #:
CERTIFICATION:
CITY PROJECT NO. 2024-05 &
CDBG PROJECT NO. 4.LQ.50-24
I hereby certify that I have reviewed and understand the diversified Federal
construction contract related requirements imposed on the Contractor(s) of HUD -
funded construction projects, including but not limited to the following:
1. The subject project is being financed with Community Development Block
Grant funds (24 CFR Part 570); and
2. This project and all related construction contracts are subject to the U.S.
Department of Housing and Urban Development's Federal Labor
Standards Provisions (HUD 4010 — revised 10/2023); and
3. This project is subject to all applicable laws and regulations as listed in the
General Summary of these Special Federal Provisions; and
4. If my bid is $200,000 or more, this project and all related contracts will be
subject to Section 3 requirements (12 U.S.C.1701 u); and
5. If the project is $250,000 or more, this project and all related contracts will
be subject to comply with the requirements of the Build America, Buy
America (BABA) Act (41 USC 8301).
CONTRACTOR'S NAME: Ramesh Bachuvala
CONTRACTOR'S LICENSE NO.: 1116157
ADDRESS: 6725 Birmingham Dr, Chino, CA 91710
AUTHORIZED REPRESENTATIVE: Ramesh Bachuvala
(Print Name)
SIGNATURE: +
DATE: N1�a0�
CDBG Required Bid Form 1290-2
Exhibit B-8
Required Bid Form
QUESTIONNAIRE REGARDING BIDDERS
Bidder has been engaged in the contracting business under the present name of
SAVI Construction Inc. , since 02/24/2024 (Date).
Present business address is: 6725 Birmingham Dr, Chino, CA 91710
Federal Tax ID: 99-1544486
Amount of Bid $
California Contractor's License No.: 1116157
Expiration Date: 04/30/2026
UEI Number: WQZKBCMLMY25 or CAGE Code
02W58
Because this project is Federally funded, it is necessary to obtain information
concerning minority and other group participation for statistical purposes. The U.S.
Department of Housing and Urban Development (HUD) uses this information to
determine the degree to which its programs are being utilized by minority business
enterprises and targeted group contractors.
A minority enterprise is defined by the Federal Government as a business that is fifty-
one percent (51 %) or more "minority -owned". Please check applicable box concerning
the ownership of your business:
❑ American Indian or Native Alaskan
® Asian or Pacific Islander/Native Hawaiian
D Black/African American
❑ Hispanic
❑ White
❑ Hasidic Jews
❑ Other
A woman -owned enterprise is defined by the Federal Government as a business that is
fifty -percent (51 %) or more woman -owned. Please check applicable box concerning the
ownership of your business:
❑ Woman/Female owned ® Male owned
A Section 3 Contractor or Subcontractor is a business concern that is more than fifty-
one percent (51 %) owned by a low or very low-income person, or over 75 percent of the
labor hours performed for the business over the prior three-month period are performed
by Section 3 workers. Please check the applicable box concerning the ownership of
your business:
IR Section 3 Business concern ❑ Non -Section 3 Business concern
The United States Department of Housing and Urban Development (HUD) is authorized to
solicit the information requested in this form by virtue of Title 12, United States Code,
Section 1701 et seq., and other regulations. It will not be disclosed or released outside of
HUD without your consent, except as required or permitted by law.
CDBG Required Bid Form 1290-3
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.
T"T,
Russian Aggression Against Ukraine Sanctions Certification 1280-1
Exhibit B-9
Required Bid Form
LIST OF SUBCONTRACTORS
SUBCONTRACTOR FED. I.D.# AMOUNT ADDRESS/PHONE NO.
Dan Francis, Competitive Asphalt Coatings, Inc.
P.O. Box 680, Highland, CA 92346 Phone: 714-743-1221
E I N 20-4561445
$15250
CA LIC # 739926 & DIR 1000012993
NAME OF SUPPLIER ADDRESS/PHONE NO. CONTRACT AMOUNT
This form is to be completed and submitted with the bid package.
CDBG Required Bid Form 1290-4
EXHIBIT B-4
Required Bid Form
Project Name:
CERTIFICATION OF BIDDER
REGARDING NONSEGREGATED FACILITIES
SAVI Construction Inc.
Name of Bidder: Ramesh Bachuvala
The above -named Bidder hereby certifies that:
I do not maintain or provide for my employees any segregated facilities at any of my
establishments, and that I do not permit my employees to perform their services at any location,
under my control, where segregated facilities are maintained. As used in this certification, the
term "segregated facilities" means any waiting rooms, work areas, rest rooms, wash rooms,
restaurants and other eating areas, time clocks, locker rooms or other dressing areas, parking
lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities
provided for employees which are segregated by explicit directive or are in fact segregated on
the basis of race, color, religion, national origin, or because of habits, local customs, or
otherwise.
I further agree to obtain identical certifications from all proposed subcontractors prior to the
award of subcontracts exceeding $10,000.
Signature:
Name (Print):
Ramesh Bachuvala
Title: President
Date: 0� �-Z o2C �
Special Federal Provisions 1550-56
EXHIBIT B-7
Required Bid Form
BIDDER CERTIFICATION ON
FEDERAL CONTRACT REQUIREMENTS
CITYWIDE MISCELLANEOUS ADA CITY PROJECT NO. 2024-05 &
Project Name: IMPROVEMENTS Bid/Solicitation #: CDBG PROJECT NO. 4.LQ.50-24
CERTIFICATION:
I hereby certify that I have reviewed and understand the diversified Federal construction contract -
related requirements imposed on the Contractor(s) of HUD -funded construction projects, including
but not limited to the following:
1. The subject project is being financed with Community Development Block Grant funds (24 CFR
Part 570); and
2. This project and all related construction contracts are subject to the U.S. Department of
Housing and Urban Development's Federal Labor Standards Provisions (HUD 4010 — revised
10/2023); and
3. This project is subject to all applicable laws and regulations as listed in the General Summary
of these Special Federal Provisions; and
4. If my bid is $200,000 or more, this project and all related contracts will be subject to Section
3 requirements (12 U.S.C.1701u); and
5. If the project is $250,000 or more, this project and all related contracts will be subject to
comply with the requirements of the Build America, Buy America (BABA) Act (41 USC 8301).
CONTRACTOR'S NAME: Ramesh Bachuvala
CONTRACTOR'S LICENSE NO.:
1116157
ADDRESS: 6725 Birmingham Dr, Chino, CA 91710
AUTHORIZED REPRESE TATIVE: Ramesh Bachuvala (print Name)
SIGNATURE:
DATE: Z,Z�
I
Special Federal Provisions 1550-57
V"i
Required Bid Form
QUESTIONNAIRE REGARDING BIDDERS
Bidder has been engaged in the contracting business under the present name of
SAVI Construction Inc.
since 02/24/2024
Present business address is: 6725 Birmingham Dr, Chino, CA 91710
Federal Tax ID: 99-1544486 Amount of Bid $
California Contractor's License No.: 1116157
(Date).
Expiration Date: 04/30/2026
UEI Number: WQZKBCMLMY25 or CAGE Code
02W58
Because this project is Federally funded, it is necessary to obtain information concerning
minority and other group participation for statistical purposes. The U.S. Department of Housing
and Urban Development (HUD) uses this information to determine the degree to which its
programs are being utilized by minority business enterprises and targeted group contractors.
A minority enterprise is defined by the Federal Government as a business that is fifty-one
percent (51%) or more "minority -owned". Please check the applicable box concerning the
ownership of your business:
❑ American Indian or Native Alaskan
® Asian or Pacific Islander/Native Hawaiian
❑ Black/African American
❑ Hispanic
❑ White
❑ Hasidic Jews
❑ Other
A woman -owned enterprise is defined by the Federal Government as a business that is fifty-one
percent (51%) or more woman -owned. Please check applicable box concerning the ownership
of your business:
❑ Woman/Female owned ® Male owned
A Section 3 Contractor or Subcontractor is a business concern that is more than fifty-one percent
(51%) owned by a low or very low-income person, or over 75 percent of the labor hours
performed for the business over the prior three-month period are performed by Section 3
workers. Please check the applicable box concerning the ownership of your business:
® Section 3 Business concern ❑ Non -Section 3 Business concern
The United States Department of Housing and Urban Development (HUD) is authorized to
solicit the information requested in this form by virtue of Title 12, United States Code, Section
1701 etseq., and other regulations. It will not be disclosed or released outside of HUD without
your consent, except as required or permitted by law.
Special Federal Provisions 1550-58
SECTION 1330
WORKERS' COMPENSATION INSURANCE CERTIFICATE
In accordance with California Labor Code Section 1861, prior to commencement of
work on the Contract, the Contractor shall sign and file with the City the following
certification:
"I am aware of the provisions of Section 3700 of the Labor Code which require every
employer to be insured against liability for workers' compensation or to undertake self-
insurance in accordance with the provisions of that code, and I will comply with such
provisions before commencing the performance of the work of this contract."
IQ We, V,
Signature
President
Title
Date
Workers Compensation Insurance Certificate 1330-1