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Home My WebLink AboutFun City Inc. Igig;� JBEAGH 18070 Gollins Avenue • BeachFvlonrvidws331n6e0 X .0606 t i ''O " nb O /l}Of WShN t ,t.0 AUG 232016 BID FORM 1 City i/ r./ ;;eae BID COVER °y`creary— 4D" ' Bid Title: EVENT RIDES RENTAL The undersigned Bidder proposes and agrees, if this Bid is accepted, to enter into an agreement with The City of Sunny Isles Beach to perform and furnish all Services as specified or indicated in the Contract Documents for the Contract Price and within the Contract Time indicated in this Bid and in accordance with the other terms and conditions of the Contract Documents. The Bidder accepts all of the terms and conditions of this Invitation to Bid and Instructions to Bidders. This Bid will remain subject to acceptance for 90 days after the day of Bid opening. The Bidder agrees to sign and submit the Agreement with other documents required by the Bidding Requirements within ten days after the date of the City's Notice of Award. In submitting this Bid, the Bidder represents, as more fully set forth in the Agreement, that: • The Bidder has familiarized himself/herself with the nature and extent of the Contract Documents, Work, site, locality, and all local conditions and Law and Regulations that in any manner may affect cost, progress, performance, or furnishing of the Work. • The Bidder has given the City written notice of all conflicts, errors, discrepancies that it has discovered in the Contract Documents and the written resolution thereof by City is acceptable to the Bidder. • This Bid is genuine and not made in the interest of or on behalf of any undisclosed person, firm or corporation and is not submitted in conformity with any agreement or rules of any group, association, organization, or corporation; the Bidder has not directly or indirectly induced or solicited any other Bidder to submit a false or sham Bid; the Bidder has not solicited or induced any person,firm or corporation to refrain from Bidding; and Bidder has not sought by collusion to obtain for itself any advantage over any other Bidders or over the City. Exact Legal Company Name: F IA l_tty i \ h Business Name (dba), if any: Street Address: I a a LI (0 5 u.) i s FBI Si— Mailing i— Mailing Address (ifdfferent): Telephone No.: 3 Q S aa r- '5 I o City of Sunny Isles Beach Invitation to Bid No. 16-08-02 W Q7tojBEA'@H . 18070 Collins Avenue iBeach Florida 33160 . ° =�r<Fr 3.05.947.0606 c. www:sne - - ibfl. t LI s `or sus F,0 Fax No.: (� Email Address: t `_a,( TrrLAn L' tty M ‘ cs. m\ . Cvm FEIN No.: COS" 0 1(0- `1 d *By signing this documen the b" er agrees to all Terms Authorized Signature: Print Name: r 1 aName:e: /61 Q-t- L p�1 e 2_ The: 2 5 I de rl 1 THE EXECUTION OF THIS FORM CONSTITUTES THE UNEQUIVOCAL OFFER OF BIDDER TO BE BOUND BY THE TERMS OF ITS PROPOSAL FAILURE TO SIGN THIS SOLICITATION WHERE INDICATED ABOVE BY AN AUTHORIZED REPRESENTATIVE SHALL RENDER THE PROPOSAL NON- RESPONSIVE. THE CITY MAY, HOWEVER, IN ITS SOLE DISCRETION,ACCEPT ANY PROPOSAL THAT INCLUDES AN EXECUTED DOCUMENT WHICH UNEQUIVOCALLY BINDS THE BIDDER TO THE TERMS OF ITS OFFER. City of Sunny Isles Beach I Invitation to Bid No. 16-08-02 1E3 - Q�1'1TQglIATRE@ BEACH 18070 Collins Avenue Beach Florida gem 305.947.0606 °` _ .. www.sibfl.net ' O \�'. �i i " ' +'. •'• Cin.OF su:l 1-14C1 BID FORM 2 ADDENDA ACKNOWLEDGEMENT INSTRUCTIONS: COMPLETE PART I OR PART II, WHICHEVER APPLIES PART I: LIST BELOW ARE THE DATES OF ISSUE FOR EACH ADDENDUM RECEIVED IN CONNECTION WITH THIS BID Addendum #1, Dated - Addendum #2, Dated Addendum #3, Dated Addendum #4, Dated Addendum #5, Dated Addendum #6, Dated Addendum #7, Dated Addendum #8, Dated PART II: X NO ADDENDUM WAS RECEIVED IN CONNECTION WITH THIS BID COMPANY NAME: 1U r1 e 44nQ AUTHORIZED SIGNATURE: DATE: (I r1 11 vV TITLE OF OFFICER: r re s 1 K]e of - City of Sunny Isles Beach 1 Invitation to Bid No. 16-08-02 BD 9 ; G Rolm 3 " ici pri Cincj At/ci 10..( 12 InU�' ✓� rci Table 1 �JJ I item- 'Descfption (.Measurements sl- ' Measurements of Age Range of :' Capiisity. -. ' :'Cost per Item:: ouantdy'in - - Equipment ' '..Play Space. Users - _ Invadory 1 Station&mgee 1 Station Bungee 25'x 25'x 25' 15'x 15'x 25' 5. 1 at a time $420/4 hats. $40 3 Jump Jump each additional hr up to8 hrs a Station&mgee 4 Station Bungee 40'x 40'x 25' 25'x 25'x25' 5. 4 at a time $880/4 hors.$150 3 Jump Jump each additional hr up to 8 hrs Airplanes _-- Airplanes 25'x25'x T 15'x 15'x7 1-6 8 a atime --_T$420/4 hats.$40 2 each additional hr up to B hrs Animal Carousel Carousel 15'x 15'x 12' 15'x 15'x 12' 1-6 8 at a time $420/4 hours.$40 2 each additional hr up to 8 hrs Fair Slide Slide 120'L x 25'x 45' 120'L x 25'x 45' All Ages 3 at a time $880/4 hours. 2 $90.00 each additional hr up to B hrs Flying Elephants Elephants 25'x 25'x 7' 25 x 25'x 7 1-6 8 at a time $465/4 hers.$40 2 each additional hr up toll hrs --- - -- -- Kiddie Carousel Pony Carousel x 15'x 17 15'x 15'x 12' 1-6 7 ata time $420/4 hags.$40 --_ 4 each additional hr up to 8 hrs Kiddie Ferris Fes Wheel — _–1B'x 10'x 18' 18'x 70'x 18' 1.10 10 at a time 5420/4 hers.$40 4 Ferris Wheeleach additional hr tp to 8 hrs Mechanical Bull Mechanical Bull 251 x 25'x 10' 25'x 25 x 10' 5. 1 at a time $420/4 hoes.S40 - 4 each additional hr up to 8 hrs Mechanical Mechanical 20'x 20'x 8' 20'x 20'x 8' 5. 1 at a time 5420/4 hers.S40 2 Surfboats Surfboard each additional hr up to8 hrs Mind Winder Mind Winder - -_50'x50'x22' 50'x50'x 22 2+ 16 at a time S880/4 hays. 2 $90.00 each additional hr up to 8 his Rock Climbing Rock Climbing Wall 32'x 75x25' 32'x 15'x25' 5. 3 at a time 5420/4 hors. 4 Wag $80.00 each additional hr up to 8 Its Space Orbiter Space Orbiter 30'x 30'x 14' 30'x 30'x 14' 5. Bat a time $465/4 haus.$40 1 each additional hr up to 8 hrs Teacups Teacups 25'x 25'x70 25'x 25'x 10 3. 16 al a time $420/4 hours.$40-- 2 each additional hr up to B hrs Trackless Train Train large flat area All Ages •12 at a time 5420/4 hours.$40 4 each additional hr up to 8 hrs Wipe Out/Log Wipe OW Log 20'x 2O x8' 20'x 20'x e' 5. xxhours. 2 2 at a time 5580/4 hours.S40 Stammer Stammer each additional hr up to B his Bounce House Castle Bounce 16x 15'x 15' 13'x 13 x 15' up to 12 6 at a time $165/4 trouts.540 10 House each additional hr up to hrs Bounce House Jungle Boum 15'x 15'x 15' 13'x 13 x 15' up to 12 6 at a time $165/4 hours.S40 10 Raise each additional hr up to 8 hrs Bounce House Sports Arena 151x 15'x 15' 13's 13 x 15' up to 12 6 at a time 5165/4 hors.S40 10 Bounce House each additional hr up to8hrs Bounce House Train Bourse 15'x 15'x 15' 13'x 13 x 75' up to 12 6 at a time 5165/4 hors.S40 1 Raise each additional hr up to8 hrs 1 Item -..Descrlptlon - Measurements of ';Measurements of• Age Range of , >ctCapacity ',..Cost per Item Otmrltlty:in. . . . . Equlpnlent•.. {Play Spaee Daus_. _ ,Inventory, Bounce House Modular Bournce 15 x 15 x 15' 13'x 13x 15' up to 12 6 at a time 5165/4 hours.$40 10 House each additional hr up to 8 hrs Bounce House Pink Modular 15x 15 x 15' 13'x 13 x 15' up to 12 6 at a time 5165/4 hours.$40 2 Bource House each additional hr up to8hrs 31n1 Castle can be used wet or 32'x 14'x 15' 37 x 14'x 15' up to 14 2 at a time 5240/4 hours.$40 4 Combo dry each additional hr up to 8 hrs Dolphin Waterslide 37 x 15'x 20' 32 x 15'x 20' All Ages 2 at a time S2951 4 hors.$40 2 Widersllde each additional hr up to 8 hrs Dolphin Watersllcew/slip s 60'x 15'x20' 60'x 15'x20' All Ages 2 at a time 54454 hors.$40---- 2 WatersBdewlBlip slide each addiacnal hr n Slide up to 8 hrs Single Lane Slip n Slip n Slide 30'x 12'x 12' 30 x 12'x 12' All Ages 1 at a time $22014 hors.S40 3 Slide each additional hr uptoehrs Dual Lane Curvy Watersiice 34'x 18'x 22' 34'x 18'x22' All Ages 2a a time 5370.00/4 hours. --_ 2 Watersilde $40 each addtbrel M up to 8 hrs _ Dual Lane Double Waterslide 34'x 18'x 22' 34'x 18'x 22' All Ages 2 at a time $370.00/4 hours. 3 Drop Watersilde $40 each addtional hr up to8 his Dual Lane Slip n Slip n Slide 37x 12'x 12' 37 x 12'x 17 All Ages 2 at a time $295/4 haus.$40 4 Slide each additional hr up to Bhrs • Dunk Tank Dunk Tank 10'x 10'x 10' 10'x 10'x 10' At least 4'tall 1 ata time 5240/4 taus.$40 4 each additional hr up to8hrs —_ _— -- . Super Slide can be used wet or 30 x 15'x 20' 3d x 15'x 20' 5. 2 at a time 5370.00/4 hours. 4 dry 540 each addtkxnal hr up to8hrs • Tropical Waterside 37x 15x 17' 37 x 15 x 17' 5+ 2 at a time $24014 hors.$40 2 Wales lde each additional hr up to8 hrs Water Wars Balloon Toss game 30 x 18'x 20' 30 x 18'x 20' All Ages 2 at a time S520/4 hours.$40 2 each additional hr up to8 his 1 31n 1 Combo can be used wet or 37 x 14'x 15 32 x 14'x 15' up to 14 2 at a time $240/4 taus.$40 2 (Enclosed) dry each additional hr up to8hrs - ' 60'Obstacle Obstacle Course 60 x 12'x 17' 60 x 12'x 17 All Ages - 2 at a time - —'5370.00/4 fours. ------ 3 Course $40 each addtiorlal hr up to8 his 75'Obstacle Obstacle Course 75'x 15'x 18' 75'x 15'x 18' All Ages 2 at a time $52014 tours. 2 Course 540.00 each additional hr up to 8 his Airborne Airborne Adventure 10 x 10 x 25' 10 x 10x 25' up to 12 1 at a time $520/4 haus.$40 1 Adventure each additional hr up to 8 hrs Baseball Inflatable Barring 10 x 10 x 8' 10 x 10'x 8' All Ages 1 ata time -W40/4 hors.$40 2 Challenge Game each addacnai hi up to8 hrs Baseball Toss Inflatable Pitching 10'x 10'x 8' lax 10'x 8' All Ages 1 ata time S240/4 hours.$40 2 Game each additional hr up to 8 hrs BaskdbalV Inflatable throwing 25'x 15'x 15' 25'x 15'x 15' All Ages 3 at a time 5370.00/4 hours. 1 Football Toss game 540 each additional hr up to 8 hrs - Bouncy Boling Bouncy Boxing 25'x 25 x 8' 25'x 25 x 8' 5+ 2 at a time $370.0014 hours. 2 $40 each addtional hr up to 8 hrs 2 Item - . a r Description • Measurements of Measurements ol 1 Age Range of , • °Cepacly Coat per Item .. _ .Quantify In . " . - Equipment- .. ,Play Space Users _ . Inventory " . Bungee Run Bungee Run 35'x 8'x 1 d 35'x 8'x 10' 5. 2 at a time $370.00/4 hours. 2 $40 each addtional hr up to 8 hrs DodgebalVSocca Dodgeball/Sc ccer 55 x 35'x 8' 55'x 35'x 8' All Ages 16 at a time $445/4 boas.440 1 Anna Arena each additional hr up to 8 hrs Dual Lane 30' Inflatable Slide 40 x 25'x30' ♦40 x 25'x 30, All Ages 2 at a time S520/4 hors -_— 2 Monster Slide $80.00 each additional hr up to 8 hrs Dual Lane can be used wet or 32 x 20'x 25' 32 x 20'x 25' All Ages 2 at a time S520/4 hours.$40 3 Screamer dry each addiecnal hr up to 8 hrs First and Goal Inflatable Tug-a-war 30 x 10'x 8' 30 x 10'x 8' 5. 2 at a time $370.00/4 hours. 1 Carne 540 each addtional hr up to8 his - - -- _- - -- - - Human Hamster Includes terrier 55'x 35'x 8' 55'x 35'x 8' 5+ 2 at a time $560/4 hags.540 4 Balls arena each additional hr up to8hrs Joust Joust 25'x 25'x 6' 25'x 25'x 6' 5. 2 at a time 5370.00!4 hours. 3 $40 each addtional hr up to 8 his Pirate Ship Inflatable play zone 32 x 15'x 15' 32'x 15'x 15' up to 10 6 at a time $520/4 hags.$40 1 each additional hr up to 8 hrs Sumo Sults Sumo Suds 14'x 141x 0' 14'x 14'x0' 8. 2 at a time $370.00/4 hours. 3 $40 each addtion& hr up to8 hrs Toddler Zero Inflatable play zone 28'x 17 x 6' 28'x 12'x 6' up to 5 -6 at a time $295/4 hags.$40 2 each additional hr up to8hrs Cotton Candy any age 1 at a time 595/4 hours.$40 5 Machine each additional hr up to 8 hrs Cotton Candy any age $15 per 50 servings unlimited Supplies Popcorn Machine any age 1 at a time $95/4 hours.$40 6 each additional hr up to8hrs Popcorn Supplies any age 515 per 50 servings uNimted Snow Cones any age 1 at a time 595/4 hours.540 6 Machine each additional hr up to8hrs • ' $now Cones any age 515 per 50 servings unlimited Supplies Carnival Booths Carnival Booth 8'x 8'x 8' 8'x 8'x 8' any age 555/4 hours 25 Crazy Cans Carnival Game Tads Top Table Provided any age 5115 00/4 taus $115/4 hags.540 2 each additional hr up to 8 hrs Penny Pitch Carnival Game Table Top Table Provided any age 1 at a time 5115/4 hours $40 2 each additional hr up to 8 hrs Plinko Carnival Game 'Table Top Table Provided any age 1 at a time 5115/4 hours.$40 2 each additional hr up to 8 hrs Pluck a Duck Carnival Game Table Top Table Provided any age 1 at a time 5115/4 hors.$40 2 each additional hr up to8hrs Rainbow Roll Carnival Game •Table Top Table Provided any age 1 at a time S115/4 hors.540 2 each additional hr up to 8 his Ring Toss Carnival Game Table Top Table Provided any age 1 at a time S115/4 bars.$40 --- 2 each additional hr up to 8 hrs •3 • Item ;Description •'Measurements of '.Measurements of ..Age Range o/ Capacity Cost per item :OuaMitAn • . ;EqulpmeM`' Ptay.Space Users a Inventory, ` . "I Tic Tac Toe Carnival Game Table Top Table Provided any age 1 at a time $1151 4 tours.$40 2' each addieonal hr up to8 hrs Kiddie Striker Clown 4'x 4'x 8' 4'x 4'x 8' 44 1 ata time 511514 hours.$40 2 - each additional hr up to 8 hrs -- Kiddie Striker Sampson 4'x 4'x 8' 4'x 4'x 8' 4+ l at a time $115/4 tours 540 2 each additional hr up to 8 hrs -- - - Adult Chaihite.samsonrte. - - - ' - - -$.75 each ..- Chains W2.500 folding chairs 6'Banquet Tables barques Table $7.00 each 500 8"Banquet Tables banquet Table Tent x.00 59.00 Each 500 ___ _ _. _ _ _ _._ _ _ _ _. .. _ _ _ ._5 10x10Tent 0 10x20 Terri Tent $115.00 110 20 x20 Tent Tent $145.00 105 ___ 20 x40 Tont _ Te __. __ $280.00 20 Clown Faceprirrirg $100.001 hr 10 - 2 Ponies Ponies -. _ ____— . $115.00/hr__ _ _ _ - 6. - _._ _ _ - - _ _ -35 Generators each generator $50.00 each supplies 2 outlets **All Items Include Attendants for the Duration of the Event (Excluding: Tents, tables, chairs &fun food supplies) 4 • SUNNY/rre ` •_ c NON - COLLUSION AFFIDAVIT • City of Sunny Isles Beach • 18070 Collin Avenue C. Co � °7• rt'o Sunny Isles Beach,FL 33160 ",0. sus'� Telephone:(305)947-0606 Fax:(305)949-3113 STATE OF FLORIDA COUNTY OF r O4 -,YJ() The undersigned being first duly sworn as provided by law,deposes,and says: This Affidavit is made with the knowledge and intent that it is to be filed with the City of Sunny Isles Beach City Commission and that it will be relied upon by said County,in any consideration which may give to and any action it may take with respect to this Bid. The undersigned is authorized to make this Affidavit on behalf of, Vun (Name of Corporation, Pa ership, Individual,etc.) F a, at ME&( Cep,Inc(A N ,formed under the laws of I . ''."jam/ (Type'yyof Business) (State) of which he is I / e S i c.A C-h f (Sole Owner, Partner,President,etc.) Neither the undersigned nor any person, firm, or corporation named in above Paragraph 10.2, nor anyone else to the knowledge of the undersigned, have themselves solicited or employed anyone else to solicit favorable action for this Bid by the City, also that no head of any department or employee therein,or any officer of the City of Sunny Isles Beach,Florida is directly interested therein. This Bid is genuine and not collusive or a sham;the person,firm or corporation named above in Paragraph 10.2 has not colluded,conspired, connived or agreed directly or indirectly with any proposers or person, firm or corporation,to put in a sham Bid, or that such person, firm or corporation, shall refrain from Bidding,and has not in any manner,directly or Indirectly, sought by agreement or collusion, or communication or conference with any person, firm or corporation,to fix the prices of said Bid or Bids of any other proposers;and all statements contained In the Bid or Bids described above true; and further; neither the undersigned, nor the person, firm or corporation named above in Paragraph 10.2,has dir-ty or indirectly submitted said Bid or the contents thereof,or divulged information or data relative thereto,to any association or to an • •- or agent thereof. RIC_ Sideof AFFIAN 'S NAM:1 AFFIANTS TITLEE, TAKEN,SWORN AND SUBSCRIBED TO BEFORE ME this ' Indy of 1^ U-St ,2001(/ 0 Personally Known X- _or Produced Identification Type of identification (Affix seal here) --146-fl--146-fl � I --146-fl t e r Ld) r\( NOTARY PUBLIC(name printed or typed) I e°" "% JEANNINE SCARBERRY MY COMMISSION M FF994065 vScfO EXPIRES:May 18,2020 DECEMBER 28,2010 1 of 7 • Sus'"r$rF r, PUBLIC ENTITY CRIMES City of Sunny Isles Beach s- y 18070 Collins Avenue c#, •r io*"�o� Sunny Isles Beach,FL 33160 or ,o" ' Telephone:(305)947-0606 Fax:(305)949-3113 SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a) FLORIDA STATUTES,ON PUBLIC ENTITY CRIMES PUBLIC ENTITY CRIMES Pursuant to the provisions of paragraph (2) (a) of Section 287.133, Florida State Statutes - "A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a Bid on a Contract to provide any goods or services to a public entity, may not submit a Bid on a Contract with a public entity for the construction or repair of a public building or public Work, may not submit Bids on leases of real property to a public entity, may not be awarded to perform Work as a Contractor, supplier, Sub-Contractor, or Consultant under a Contract with any public entity, and may not transact business with any public entity in excess of the threshold amount Category Two of Sec. 287.017, FS for thirty six months from the date of being placed on the convicted vendor list". THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. 11.1. This sworn statement is submitted to City of Sunny Isles Beach y n 7 d by �pmf mdmdua�S rtmeeand 6iiel ` f e s t e vi - I j - for r1 n • name• en sui is ng swam s"emen whose business address is: (a 'eco sW lax Sf 011"( anti' \ I I 331 10 II and (if applicable) its Federal Employer Identification number(FEIN) is (0 S— 05 b 3yaS. (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn statement: .) 11.2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any Bid or Contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 11.3. I understand that "convicted" or"conviction" as defined in Para. 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trail court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere. 11.4. I understand that an "affiliate" as defined in Para. 287.133(1)(a), Florida Statutes, means: a.) predecessor or successor of a person convicted of a public entity crime; or b.) Any entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executors, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair DECEMBER 28,2010 2 of 7 market value under an arm's length agreement, shall be a prime fade case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 11.5. I understand that a "person" as defined in Para. 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding Contract and which Bids or applies to Bid on Contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "persons" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of any entity. 11.6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this swom statement. (Indicate which statement applies.) Neither the entity submitting this sworn statement, nor any of it's officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THR- HOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF A CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. By: (l as p • Z (Prir d Name)/S j dear- (Title) c{G� I COSworn to and subscribed before me this 1 f day of - U- , 20 1 C , by A T It'C t �e z (AFFIX NOTARY STAMP HERE) / _ . .= 4L_4A 'aams P� '%�♦ JEANNINE SCARBERRY Signatu ;•. Notary Public-State of Florida �A1R Mr coseassioN FF994065 #0ET EXPIRES:MEEIR2020 T e6-nn; r4 Sey j-,F r Print or Type Commissioned Name Personally Known OR Produced Identification Type of Identification Produced 10/1998 3 of 7 o‘4194111;_ sot.N ,t`Ff s. _ EQUAL OPPORTUNITY / u AFFIRMATIVE ACTION *.�'' •, °•°,. City of Sunny Isles Beach ''o. .v� • 18070 Collins Avenue • Sunny Isles Beach,FL 33160 Telephone:(305)947-0606 Fax:(305)949-3113 EQUAL OPPORTUNITY/AFFIRMATIVE ACTION STATEMENT The contractors and all subcontractors hereby agree to a commitment to the principles and practices of equal opportunity in employment and to comply with the letter and spirit of federal, state, and local laws and regulations prohibiting discrimination based on race, color, religion, natio al r ion, sex, age, handicap, marital status, and political affiliation or belief. Signed: Title: f—Pf 2 S-1 c(2,n TL Firm: n C,17yI \ h C Address: l�^n ac- Lo ,5� I a 8 5 t I -icalc , Pt 3-61 “0 DE°BAem 2e,2010 4 of 7 Ot S, $N•istFfa CONFLICT OF INTEREST • City of Sunny Isles Beach 18070 Collins Avenue et„ • s o•`oo Sunny Isles Beach,FL 33160 '" Telephone:(305)947-0606 Fax:(305)949-3113 CONFLICT OF INTEREST STATEMENT The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. STATE OF FLAtRIDA COUNTY OF(1 �/1` BEFORE ME, the undersigned authority, personally appeared \C /% Lop t z , who was duly sworn, deposes, and states: 131. 1 am the pre SlQnf of ti CAL 1 let I with a local office in a,,,; �L and principal office in t0 Mt 18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, Bid No. 16- OK--Oa described as: L . The Affiant has made diligent inquiry and provides the information contained in this Affidavit based upon his own knowledge) V Cr)t P-i d2 S Re Ink-o- 18.3 The Affiant states that only one submittal for the above Bid is being submitted and that the above named entity has no financial interest in other entities submitting Bids for the same project. 18.4 Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for the above Bid. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project. 18.5 Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. 18.6 Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 18.71 certify that no member of the entity's ownership or management is presently applying for any employee position or actively seeking an elected position with the City of Sunny Isles Beach. 18.8 I certify that no member of the entity's ownership or management, or staff has a vested interest in any aspect of the City of Sunny Isles Beach. 18.9 In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above named entity, will immediately notify e City of Sunny Isles Beach. I D. -d s day of c&_%1 , 2017. al- . ales Lona> Pres. cif)nt- .7 I• w Print or TypeN5mme acid Title /- _ Sw9rn to and subscribed before me this 14.h day of 1 L.A.S"1 , 201b.. Personally Known OR O Produced Identification ;Type of Identification NOTARY PUBLIC STATE OF FLORIDA Pa': JEANNINESCARBERRY MY COMMISSION Y FF994065 itr nA' EXPIRES:May 18,20220 DECEMBER 28,2010 d 5 of 7 O'y0$NT It`EJ. DISPUTE DISCLOSURE %ter City of Sunny Isles Beach 18070 Coigns Avenue '•cam.'• F E o°Cll. 0' Sunny Isles Beach.FL 33160 ''o. .vr '� Telephone:(305)947-0606 Fax:(305)949-3113 DISPUTE DISCLOSURE FORM Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please explain in the space provided,or on a separate sheet attached to this form. 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5) years? YES NO 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? YES NO 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? YES NO X If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the monetary amounts of extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City of Sunny Isles Beach. 1 n s; ` 1nC Tit h (o Firm ANA Date Art,/ Lopez �reS; CIr Qa1— Auth'¢ed Signature' Print or Type Nam and Title DECEMBER 28,2010 6o17 • `ye$NY 04(FJ 0 'atm= ANTI - KICKBACK City of Sunny Isles Beach • 18070 Coffins Avenue '•• °'• r i ot�eo Sunny Isles Beach,FL 33160 or ,us 't Telephone:(305)947-0606 Fax:(305)949-3113 ANTI-KICKBACK AFFIDAVIT STATE OF FLORIDA ) COUNTY OF Miami -'bacle) I, the undersigned, hereby duly sworn and deposed say that no portion of this sum herein Bid will be paid to any employees of the City of Sunny Isles Beach or its elected officials as a commission, kickback, reward or gift, directly or indirectly by : or any member of my firm or by an officer of the corporation. By: Title: 71 ' 4) . f The foregoing instrument was acknowledged before me this I Q/41 day of wst , 20 , by Ate_x l apeL [name of pe n], as Pre 5; eh+ [type of authority], for Fu.n C' "tk-s\ , t(AO [name of party on behalf of whom instrument was executed]. AFFIX NOTARY STAMP HERE: QJEANNINzsctnitRRY tary Public — State of Florida . ►tvmwMISvDNIFF9019e5 S•\r.00 D0'tR :May tkrao f 6-hn; ne 1 Print or Type Commissioned Name Personally Known /\ OR Produced Identification Type of Identification Produced DECEMBER M.2010 7 of 7