HomeMy WebLinkAboutCertification StatementCertification Statement
Please quote on this form, if applicable, net prices for the item(s) listed. Return signed original and
retain a copy for your files. Prices should include all costs, including transportation to destination.
The City reserves the right to accept or reject all or any part of this submission. Prices should be
firm for a minimum of 120 days following the time set for closing of the submissions.
In the event of errors in extension of totals, the unit prices shall govern in determining the quoted
prices.
We (1) certify that we have read your solicitation, completed the necessary documents, and propose
to furnish and deliver, F.O.B. DESTINATION, the items or services specified herein.
The undersigned hereby certifies that neither the contractual party nor any of its principal owners or
personnel have been convicted of any of the violations, or debarred or suspended as set in section
18-107 or Ordinance No. 12271.
All exceptions to this submission have been documented in the section below (refer to paragraph
and section). 1
EXCEPTIONS• `)/ A
We (I) certify that any and all information contained in this submission is true; and we (I) further
certify that this submission is made without prior understanding, agreement, or connection with any
corporation, firm, or person submitting a submission for the same materials, supplies, equipment, or
service, and is in all respects fair and without collusion or fraud. We (I) agree to abide by all terms
and conditions of this solicitation and certify that I am authorized to sign this submission for the
submitter. Please print the following and sign your name:
SUPPLIER NAME. J e\C)-- k-^^ ` ev ` `^^1 os\^ C '�-
ADDRESS. tact 9\61Ct `_
PHONE: % M Z -Zda c7 FAX• s:\`k -ssa - °t cl
EMAIL: - Q-- 4 t ^C iW'&I L�PERd -
SIGNED BY- V " `
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TITLE: v4\-$-J\ ' DATE• - Z "
FAILURE TO COMPLETE. SIGN. AND RETURN THIS FORM SHALL DISQUALIFY THIS BID.
Page 2 of 48
Certifications
Legal Name of Firm:
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Entity Type: Partnership, Sole Proprietorship, Corporation, etc.
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Year Established:
Office Location: City of Miami, Miami -Dade County, or Other
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Occupational License Number:
3Z_ Zoo
Occupational License Issuing Agency:
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Occupational License Expiration Date:
2 as(
Respondent certifies that (s) he has read and understood the provisions of City of Miami Ordinance
No. 10032 (Section 18-105 of the City Code) pertaining to the implementation of a "First Source
Hiring Agreement.": (Yes or No)
Do you expect to create new positions in your company in the event your company was awarded a
Contract by the City? (Yes or No)
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In the event your answer to question above is yes, how many new positions would you create to
perform this work?
01 0,
Please list the title, rate of pay, summary of duties, number of positions, and expected length or
duration of all new positions which might be created as a result of this award of a Contract.
Minority/Women Business Affairs Registration Status: Hispanic, Female, Black o
Page 3 of 48
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Will Subcontractor(s) be used? (Yes or No)
1. Name and Address of Subcontractor:
1. Description of Work to be Performed
2. Name and Address of Subcontractor
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2. Description of Work to be Performed
Does the City of Miami Living Wage Ordinance apply to this formal solicitation? ( See Section
1.40 of the General Terms and Condtions) (Yes or No)
Service Total Contract Amount( which includes base term and renewal options):
Is this service contract a citywide contract? (Yes or No)
If the above answer is no, please indicate the name of the city (end user) department that your
contract will serve:
Provide brief description of the project or service to be provided
I/We hereby state compliance with the City of Miami Living Wage Ordinance, Section 18-556
through Section 18-559 as summarized in Section 1.40 of the General Terms and Condtions? (Yes
or No)
Name and Address of Company to Service Generator Sets and Transfer Switches at all Locations
2-0
Page 4 of 48
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Name and Telephone Number of Technician Servicing Generator Sets and Transfer Switches at all
Locations
Reference #1: Name and Address of Company nn
Reference #1: Contact Name and Telephone Number
Reference #1: Amount of Contract
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Reference #1: Detailed Description of Work Performed
Reference #2: Name and Address of Company
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Reference #2: Contact Name and Telephone Number
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Reference #2: Amount of Contract
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Reference #2: Detailed Descriptionipof Work Performed
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Reference #3: Name and Address of Company
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Reference #3: Contact Name and ,I 1ephone Number
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Reference #3: Amount of Contract
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Reference #3: Detailed Description of Work Performed
Page 5 of 48
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Generator Set / Transfer Switch Service: Company Name and Address
Generator Set / Transfer Switch Service: Service Technician Contact Name and Telephone
Number 'R
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Have you ever failed to complete any work awarded to you? If so, where and why
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Give owner names, email, phone #'s, surety, and project names for projects where your surety has
intervened to assist in completion of the project.
Name of your proposed project manager and supervisor and give detail of their qualifications and
experience in managingnnsimilar work
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List and describe Performance or Payment Bond claims made to your surety during the last 5 years.
List all claims, arbitrations, mediations, civil actions, administrative hearings and lawsuits brought
by or against the bidder during the last 5 years.
What is the nature and amount of the 3 largest change orders submitted by the bidder within the last
5 years.
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Have you ever failed to complete any work awarded to you? If so, where and why.
Page 6 of 48