HomeMy WebLinkAboutHolywingz
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BID FORM.
FOR THE
JANITORIAL MAINTENANCE SERVICES
f40TE: The quantities shown in this bid form are estimates only! They may vary
significantly from the actual quantities ordered by the Cty. Payments shall be for the
units ordered, placed, and accepted by the City. The Bidder, by signing this Bid Form
and Contract, fully acknowledges that he/she will receive no additional compensation
(no overhead, no anticipated profits, etc.) other than the bid unit price of the items
times the number of items authorized, ordered, placed, and aa:epted by the City.
7.6. Bid Form
ITEM DESCRIPTION OUANTITY UNIT BID TOTAL
A. OFFICES
X $ $
Al City Hall Offices 48 300D.uf 300{). Cfl)
Per Montfl of
Cleanlna One Oft'Ice =
X $ J 006. ;rrf $
A2 CIty Hall Cubicles 40 )- 0 00. {f2r
Per Month of
Cleanlna One OJblcal =
X $ $
A3 Pelican Community Park Offices S 3000.rJO 3 ()O c). (12)'
Per Montfl of
Oeanlna One Office =
X $ $
A4 Pelican Community Park Cubides 4 ~OOb,rYr JOOO,oo
Per Montfl of
Ceanina One OJblcal =
X $ $
AS Public Works Offices 6 30 () fJ,V'lJ 30 ()(). "
Per Montfl of
Ceanlna One Office =
$
A SUBTOTAL ~(300,~'
B. KITCHEN AREAS
X $1 00 I). 0 () $
Bl City Hall Kitchen Areas 4 /fl)O(),"
Per Month of Deanlng
One Kitchen Area =
RECEiVED
JUN 2 4 2008 '
PAGE 29 OF 78
.. -
. I
x $ $
B2 Pelican Community Park Kitchen Areas 1 It( 0 () I rJlf
Per Montfl of Cleaning
One Kitchen Area =
X $ ) OOO,QC $
B3 Public Works Kitchen Areas 1
Per Month of Ceanlng
One KItchen Area =
B SUBTOTAL $:JL{O() ,t?)
C. HALLWAYS AND COMMON AREAS
X $ "DOl 00 $
Cl city Hall 4
Per Montfl of
One Area =
X $ :5 ()Q.dJ J
C2 Pelican Community Park 1
Per Month of
One Area =
X $ 6oo..(f( J
C3 Public Works Office Building
Per Month of
One Area =
$
C SUBTOTAL 1S- 0 () fro ,/
D. FOYER AND RECEPTION AREAS
X $ $
Dl City Hall Foyer and Reception Areas 4 ;;{)O, GO
Per Month of
One Area =
X $ . $
D2 Community Center Foyer and 2 SOD'DO
Reception Area
Per Month of
One Area =
X $ $
D3 Public Works Foyer and 1 :; () (j.o6
Reception Area
Per Month of
One Area =
$ ~
D SUBTOTAL )~ 0 0/ () j
E. RESTROOMS
PAGE 30 OF 78
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I
I
I
I
I
I
X$ DO. Du $
El Oty Hall Restrooms 13 g Per Month of
One Area =
X$;}Ob,QO $
E2 Community Center Restrooms S
Per Montfl of
One Area =
X $ $
E3 Park and Beach Access Restrooms 6 600 t 6 6
Per Montfl of
One Area =
$
E SUBTOTAL 0; /)(). /fF-
F. ELEVATORS
X $ $
Fl Oty Hall Elevators 3 ;)00 tOO
Per Montfl of Oeanlng
One Elevator =
X $ $
F2 Community Center Elevators 1 Per M?nR /Je~(!.l)
One Elevator =
$
F SUBTOTAL !;iJd ,/)1\
G. COMMISSION CHAMBERS ~
X $ 3l1J,6O $
Gl Oty Hall Commission Chambers 1
Per Montfl of
Ceanlna =
$
G SUBTOTAL 300 ~ (J)) v
H. MISCELLANEOUS ITEMS
X $ $
H1 Police Department Holding Cells 2 S06,iJO
On Call Per Cell Per
Ceanina =
X $ $
H2 Pelican Community Park Creative Arts 1 jOO,O{J
Room
Per Montfl Per
Room Per Ceanlna =
PAGE 31 OF 78
, \
I .
x $ $
H3 Pelican Community Activity Rooms 3 ~ OPer~oJ2,O
aeanlna Per Room =
X $ $
H4 Pelican Community Park Gymnasium 1 J ~~~~ c9
Cleanina =
X $ $
H5 Pelican Community Park Gymnasium 1 4~Q~QfO
Concession Stand
Deanlna =
L dD\ar~ C-:fjJ"d~~Coverl'V\ef\t XV iOOOff $
H SUBTO ~L I r e.. tvlO'l;tk O~ 3~~o a
c..le~ It_~ b~ i~"'!+'
I. STAIRWELLS '-I
x $ $
11 City Hall 1 2 & D. 00
Per Month of
aeanlna =
X $ $
11 Pelican Community Park 1 LOO. C9,G
Per Month of
DeanlnG =
$
I SUBTOTAL I ttQo 10{)
GRAND TOTAL
$
NOTE: The quantities shown in this bid form are estimates only! They may vary
significantly from the actual quantities ordered by the City. Payments shall be for the
units ordered, placed, and accepted by the City. The Bidder, by signing this Bid Form
and Contract, fully acknowledges that he/she will receive no additional compensation
(no overhead, no anticipated profits, etc.) other than the bid unit price of the Items
times the number of items authorized, ordered, placed, and accepted by the City.
Grand Total (based on the estimated quantities) written out In words:
Dollars and
Cents.
PAGE 32 OF 78
-
SECTION 22
BID CHECKUST
THE FOLLOWING ARE REQUIREMENTS OF THIS BID. USE OF THIS CHECKUST WILL HELP ENSURE
THAT YOUR SUBMISSION IS COMPLETE.
Place a check mark in the "Done" column as you complete and enclose each item.
./
./
./
./
./
./
./
./
./
./
./
./
./
./
./
0'
Bid Response Sheet/Bid Form/Bid Specifications
Certiflcate(s) of Insurance
..~ftt:dt~~of-Competencies- ~
Local Business Tax (Occupational Business Ucense)
State License( s)
List of Proposed Sub-Contractors
Bidder Qualification Statement
Non-Collusion Affidavit
Non-Kickback Affidavit
Public Entity Crimes Sworn Statement
Acknowledgement of Conformance with OSHA Standards
Equal Opportunity/AffIrmative Action Statement
Conflict of Interest Statement
Dispute Disclosure Form
Bid Checklist
This checklist must be part of the Bid. Please read the entire Bid documents thoroughly to ensure that
your submission is complete.
PAGE 78 OF 78
END OF SECTION
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ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DA TE (MMIDDIYY)
06/23/08
I'RODUCEIt TillS CERTIFICATE IS ISSUED AS A MATTER OF INFORl\IATlON
ED'S INSURANCE ONLY AND CONFERS NO RIGHT UPON THE CERTIFICATE
4583 N DIXIE HWY HOLDER TillS CERTIFICATE DOES NOT AMEND, EXTEND OR
POMPANO BCH, FL 33064 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
(954) 782-0411 INSURERS AFFORDING COVERAGE
INSUllED
HOLYWINGZ CLEANING SERVICES INSUltEIt A: American Vehicle Insurance Company
1627 NW 14TH CR INSUltEIt B:
SUITE INSUltEIt C:
161 INSUltEIt D:
POMPANO BEACH, FL 33069 INSUltEIt E:
COVERAGE
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOT WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH
RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSll l'OLlCY EFFECTIVE POLICY EXI'IRATION
LTIt TYPE OF INSUltANCE POLICY NUMBEIt DATE (MM/DDIYY) DATE (MM/DDIYY) LI~IITS
ENERAL LIABILITY EACH OCCURENCE S 1000,000
II COMMERCIAL GENERAL FIRE DAMAGE(Any one 100,000
Ire) S
LIABILITY
PLAIMS MADE 0 OCCUR MED EXP(Any one person) S 5,000
A b 02/27/2008 02/27/2009 PEltSONAL AND ADV 1000,000
GL0511058437 INJURY s
b IcENERAL AGGREGATE S 2000,000
IcEN'L AGGREGATE LIMIT APPLIES PRODUCTS - COMP/OP 2000,000
PER: AGG S
o POLICY D PltOJECT D LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S
ANY AUTO ea accident)
ALL OWNED AUTOS BODlL Y INJURY S
SCHEDULED AUTOS Per person)
HIRED AUTOS BODILY INJURY S
NON-OWNED AUTOS Per accident}
PROPERTY DAMAGE S
Per accident)
GARAGE LIABILITY AUTO ONL Y - EA S
ACCIDENT
q ANY AUTO IoTHERTHAN EA ACC S
AUTO ONL Y: AGG S
EXCESS LIABILITY EACH OCCURANCE S
~OCCUR DcLAIMS MADE AGGREGATE S
S
R~EDUCTlBLE . S
RETENTION S
VORKEltS COMPENSATION AND bwc STATUTORY
EMPLOYERS LIABILITY LIMITS QJTHER
E. L. EACH ACCIDENT S
E.L.DISEASE-EA
EMPLOYEE S
E.L.DISEASE - POLICY
LIMIT S
OTIIEIt
DESCltlPTlON OF OI'EltATIONS/LOCATIONSIYEIIICLES/EXCLUSIONS ADDED BY ENDORSE~IENT/SI'ECIAL PROVISIONS
CLEANING OF BUSINESS
CERTIFICATE HOLDER I I ADDITIONAL INSURED:INSUItED LETTER: I CANCELLATION
1I0ULD ANY OF TilE ABOVE DESCRIBED POLICIES BE CANCELLED BHOltE TilE
EXPIIlATlON DATE TlIEREOF, TilE ISSUING INSUllEll WILL ENDEAVOR TO MAIL JQ
DAYS WltlTTEN NOTICE TO TilE CERTIFICATE 1I0LDEIt NAMED TO TilE LEFT, BUT
FAILUltE TO DO SO SIIALL IMI'OSE NO OBLIGATION OR LIABILITY OF ANY KIND
UPON TIlE INSUltEIt, ITS AGENTS Olt ItEPRESENTATlVES.
SUNNY ISLES BEACH GOVERNMENT CENTER
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18070 COLLINS AVE
SUNNYISLES BEACH, FL 33160
Faxed to:
\UTIIORIZED REPRESENTATIVE
// G //7
/' h ")~r
ACORD 26-8 (7/97)
ACORD CORPORATION 1988
http://amelia.e-bode. com/innovarel gl/S endF ormPreview AndSend. cfm
6/23/2008
and compliance or noncompliance with any formalities connected with the Contract or the changes do not
affect the Surety's obligation under this Bond.
Signed and sealed this
d1
-
day of ~ l (1 17 e ,20 (Jr)'g
BY: ~I() Ijp)'f!J' Z-
(Na, of poration)
~J%.n~~f1'<~
~~d mr/,'Qd"/1 (OW/lfi J
me and n~ Signed Above) ""
WITNESS:
Seaetary
(CORPORATE SEAL)
IN THE PRESENCE OF; INSURANCE COMPANY:
BY:
*Agent and Attorney-In-Fact
* (Power of Attorney must be attached)
(Add~) E
4583 N. DIXIE HIGHWAY
(Clty/State~O BEACH, J-L 33064
954-782-0411
(Telephone)
STATE OF FLORIDA )
COUNTY OF (j-(,.J- ~
The foregoing instrument w~cknowledged before me thiS~ day of Cfv-r' ,
20~ by ~ ~ U7-1.C?- [name of person], as
[type of authority], for ..f (; /7 tvl1'1r'Z.
[name of party on behalf of whom instrument was executed].
AFfIX NOTARY STAMP HERE: ~~__of FIoI1c1a
Print or Type Com'mls _ :" ~me EDDY W. FABRE
~ g~~ }*i MY COMMISSION # DO 505609
Personally Know OR Produced Identification "t",,* ""PIRES, J..anuary 10, 2010
Type of Identi tion Producecl . . .... " ended T~~~ary Public Underwriters
PAGE 68 OF 78
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Application for Employer Identification Number
Form 55-4 (For use by omployors, corporations, partnorships, trusts, ostatos, churchos,
(REV. D~c~mb~r 2001) govornmont agencios, Indian tribal ontitios,cortain individuals, and othors)
D~parlm~~l of tho Ttusuty'" ... K f d
Intornal Rovonuo Sorvice ,. See separate Instructions for each line. ,. eep a copy or your recor s.
Legal name 01 entity (or individual) for whom the EIN is baing requested.
r ,;
EIN 20-8715972
03903 03/27/2007
i:-
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2
Sa Street address (if different) (Do not enter a P.O. box)
4b City, state, and ZIP code
POMPANO BEACH, FL 33069
6 County and state where principal business is located,
5b City, state, and ZIP code
BROWARD FL
70 Name 01 principal officer, general partner, grantor, owner, or trustor
7b SSN, ITIN, or EIN
"
6a Type of entity (check only one box)
00 Sole proprietor (SSN) 5921 03 17473
o Partnership
o Corporation (enter lorm number to be filed)~
o Personal service corp.
o Church or church-controlled organization
o Other nonprofit organization (specify) ~
o Other (specily)
8b II a corporation, name 01 state or loreign country
(if applicable) where incorporated
9 Reason for applying (check only one box)
I!l Started new business (specify type) ~
CLEANING
o Hired employees (Check the box and see line 12.)
o Compliance with IRS withholding regulations
o Other (specily)~
.10 Date business started or acquired (month, day, year) 10/01/2006 11 Closing month 01 accounting year
12 First date wages or annuities were paid or will be paid (month, day, year) Noto:lf appliC:3nt Is a withholding agent, enter date income will first
be paid 10 nonresident alien, (month, day, year)........................................................ ~
13 Enter highest number of employees expected In the next 12 months. Noto: If the applicant ... Agricultural Household Other
does not expect to have any employees during the period, enter "-0.". ....................................,. 0 0 0
14 Check one box that best describes the principal activity of your business. 0 Health care & social assistance 0 Wholesale.agenllbrok€lr
o Construction 0 Rental & leasing 0 Transportation & warehousing 0 Accommodation & food service 0 Wholesale.other 0 Retail
o Real estate 0 Manufacturing 0 Finance & insurance 00 Other (specify)CLEANING
15 Incicata principnl line 01 tnl'lrchandis.. sold; specific construction work done; products produced; or services provided.
JANITORIAL SERVICE 6461
160 Has the applicant ever applied for an employee identification number lor this or any other business .-----------.0 Yes
Note: If "Yes. please 'complete lines 16b and 160.
16b II you checked "Yes" on line 16a, give applicant's legal name and trade name shown on prior application il different from line 1 or 2 above.
Lagi'll name ~
Trada nama ~
16c Approximata date when, and city and state where, the application was flied. Enter previous employer identification number if known.
Approximate date when filed (mo., day, year) City & state where flied Previous EIN
o
B
o National Guard 0 Statel10cal government
o Farmers' cooperative 0 Federal government/military
o REMIC 0 Indian tribal governments/enterprises
Group Exemption Number (GEN) ~
Estate (SSN of decedent)
Plan administrator (SSN)
rflJst (SSN of grantor)
State
Foreign country
o Banking purpose (specify purpose) ~
o Changed type 01 organization (specify new type) ~
o Purchased going business
o Created a trust (spacify type) ~
o Created a pension plan (specily type) ~
~NO
Com liMe this section onl
Dasignae's name
's EIN and answer uestlons about the com letlon of this lotm.
oulg~oe'slol~phono ~umber (Incl. aroa codo)
( )
DOIIg~oo's fall ~umber (Include aroa codo)
( )
Third
Party
Dosignoo
Addrass and Zip Code
Under pon~iijn of perjury. I dO(:I~r. lh~ll h~ve ..~minod this applleallo~. and 10 tho besl 01 my knowlodQo and bellol. Ills llUO. corroel. and complolo.
Name and title (Please type or print clearly.) ~
Si nature 03/27/2007
For Prlvaby Act and Paperwork Reduction Act Notice, see separate Instructions. Cat. No, 16055N
(Rev, 12.2001)
SECTION 9
BIDDER QUAUFlCAnON STATEMENT
The Bidder's response to this questionnaire will be utilized as part of the City's overall Bid Evaluation and
Contractor selection.
The undersigned guarantees, by signature, the truth and accurac.y of all statements and the answers
contained herein.
9.1. Please describe your company In detail.
:1an'ltoflal6e W~ndou) ~lea{\~I1~
I i
9.2. The address of the prindpal place of business is: ~~. \"~fl3'. / ~ 2-1- M vJ 14~.: r@le#/G/
l..,~ 'j, ~D 1V\~{,.(10 ~ 2trtLLM..l{ S<<..te lo~ ! ~ I I --7 pOntfanD l3eet-e.A r::-L
~o lVIftl"" BeM-lq::'L '3"306'f /0t (eS5 "3"30(; 9
9.3. Company telephone number: ~
~y) J36- -:f141-
9.4. Number of employees:
9.5. Number of employees assigned to this project:
9.6. Company's Identification Number(s) for the Internal Revenue Service:
cJ () - is 1-15 r 7--2
9.7. Miami-Dade County and City of Sunny Isles Beach Occupational Ucense Number(s):
&6 - t9006/'1-c;g
9.8. How many years has your organization been In business?
2- y12S.
9.9. What similar engagements Is your company presently working on? If none, write "none".
(\Of\t
PAGE 51 OF 78
SECTION 10
NON-COLLUSION AFFIDAYrr
STATE OF FlORIDA ~
COUNTY OF ~I(\,~
The undersigned being first duly sworn as provided by law, deposes, and says:
10.1. This Affidavit Is made with the knowleclge and intent that it is to be filed with the Oty of Sunny
Isles Beach Oty 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.
10.2. The undersigned Is authorized to make this Affidavit on behalf of,
(Name of~,\~:teMduaI, etc.)
a,Sa n ~ +r)( " a I . formed under the laws of
(Type of Business)
of which he is 111 h I/aa .
jI . (So~, Partner, President, etc.)
10.3. Neither the undersigned nor any person, firm, or corporation named in above Paragraph 11.2,
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 oty, also that no head of any department or employee
therein, or any officer of the Oty of Sunny Isles Beach, Florida is directly interested therein.
r:/orcl)a
(State)
10.4. This Bid is genuine and not collusive or a sham; the person, firm or corporation named above in
Paragraph 11.2 has not colluded, conspired, connived or agreed directly or indirectly with any bidder or
person, firm or corporation, to put in a sham Bid, or that such person, firm or corporation, shall refrain
from bidding, 'ano has not in any manner, directly or indirectly, sought by agreement or collusion, or
communicatfon or conference with any person, firm or corporation, to fix the prices of said proposal or
proposals of any other bidder; and all statements contained in the proposal or proposals described above
true; and further; neither the undersigned, nor the person, firm or corporation named above In
Paragraph 11.2, has directly or indirectly submitted said proposal or the contents thereof, or
diwiged information or data relative ereto, to any association or to any member or agent thereof.
U
(Affix seal here)
20r€'
Personally Known
Type of identification
cf~rntceI~entification
...."", SANDRA GRACEY-SIBBLE
",~>S'.y ~(J~,~ Notary Public. State of Florida
~-:.
:' .. ... . ~ My Commission Expires Jun 8, 2011
~"" ~. ~'<~ Commission # 00 651690
"'~:.~. Of f\.Ct..",'" Bonded Through National Notary 0 OF SECTION
""',,
PAGE S6 OF 78
SECTION 21
ANn-KICKBACK AFFIDAVIT
STATE OF FLORIDA )
COUNTY OF ~
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 me or any
member of my firm or by an officer of the corporation.
By:
---ili il At ttMr Ij? 11 :x IflJ /4~/
nl A ')/1 p~r
Title:
instru~~t was
20 0 by
,J.
befo(e me thi~ day of
[type of authority], for
[name of party on behalf of whom instrument
A
"",~y P::"" A. R . BlE
i~m. '\~'~ Notary Public. Slale of Florida
~. * .: . ~ My Commission Expires Jun 8, 2011
~~^' c~"$:: Commission # DO 651690
',:t'" Of F\.l.r..,"
.....""",' Bonded Through National Notary Assn.
Personally Known OR prodU~dentificatiOn
Type of Identification Produced P L ~
END OF SECTION
PAGE 77 OF 78
SWORN STATEMENT PURSUANT TO SEC'nON 287.133(3)(a)
FLORIDA STATUTES, ON PUBLIC ENltTY CRIMES
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 Otv of Sunnv Isles Beach Cltv Commission
by (\1 A ('l j \+~ (r~ al' n - 0 (t) {\ () (
~tihej J
for tlt\\ I ) I I) ~ Y\U l7
[print ~ submitllng ~ statement)
whose business address Is:
U 3 0, ,- p () I'\A ~.ht\O j)~( IL U17-LL (~ () 2-.
~ () t\J'.fo.r-. 0 &P~ r: (_ "3 r1 () ~ q
and (If applicable) its Federal Employer Identification number (FEIN) is ? r) - if~ / S 972
(If the entity had no FBN, indude 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(l)(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 indicbnent 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 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), Rorida 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,
PAGE 58 OF 78
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 swom statement, nor any of it's officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management ot
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.
M The entity submitting this swom 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 Rorida, 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 swom 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
PUBUC ENTITY IDENTIFIED IN PARAGRAPH 11.1 (ONE) ABOVE IS FOR THAT PUBUC ENTITY ONLY
AND, THAT THIS FORM IS VAUD THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS
FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBUC ENTITY PRIOR TO
ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION
287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY, CHANGE IN THE INFORMATION
CONTAINED IN THIS FORM.
By:
.J..~ day of
20.oL by
Personally Known OK t'rstG u J.d~ntificatlon
Type of Identification Produced _rC 4J '-
END OF SECTION
L-----"
PAGE S9 OF 78
-
SECTION 17 .
ACKNOWLEDGMENT OF CONFORMANCE
WITH OSHA STANDARDS
To: City of Sunny Isles Beach
We, ---Ji~rl ~ ';j /2 . hereby acknowledge and
agree that we, as the Prime Contractor for the Janitorial Services Maintenance Services Contract,
-tAl t as spedfled, have the sole responsibility for oompliance with all the requirements of the
Federal Occupational Safety and Health Act of 1970, and all State and local safety and health regulations,
and agree to indemnify and hold harmless the City of Sunny Isles Beach against any and all liability,
daims, damages losses and expenses they may incur due to the failure of
[Sub-Contractor]
[Sub-Contractor]
(Sub-ContractDr)
to comply with such act or regulation.
( H () { 'f ()J //7 3~)
!YIa(~ I-M rilg?'l
CONTRACTO
()(urt'Pr
TITlE
BY,IJt; )/t:
END OF SECTION
PAGE 73 OF 78
SECTION 18
EQUAL OPPORTUNITY I 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, national region, sex, age, handicap,
marital status, and political affiliation or belief.
Firm:
IJI!~ 1/d/l47'q~
n'L)ner-
1!(}/fI~JI /y '?
<<3 3. I?IJM #.t?/I () 02rY(t)h;/ !r,w
, I /
/1)21IJ/1Ij'.?/ltJ Ae.;eA. ,H 3Yt%,9
Signed:
Title:
Address:
END OF SEmON
PAGE 74 OF 78
-
SECTION 19
CONFUCT OF INTEREST STATEMENT
STATE OF FLORIDA A
COUNTY OF ~ It P
-
BEFORE ME, the undersigned authority, personally appeared \Y\l1.(i-t\?li f(: jJ rJ . who
was duly sworn, deposes, and states:
19~. I am
~(JJ ~(Z-
prlndpal fflce In
the
o (A )~e..-" of
with a local office n ~ ~ ~ POYlA &20'1.0 t 2. r~ 1J..-2.,J# tgfRj
. DI~fJUt\.O ~.2...e. i-L 33661
19.2. The above named entity is submitting a Bid for the Oty of Sunny Isles Beach, Bid No.
()"8 ..- 0 6 - O(). described as: Janitorial Maintenance Services.
19.3. The Affiant has made diligent inquiry and provides the information contained in this Affidavit
based upon his own knowledge.
19.4. The Affiant states that only one submittal for the above bid is being submitted and that the
above named entity has no f1nandallnterest In other entities submitting bids for the same project.
19.5. Neither the Affiant nor the above named entity has directly or Indirectly entered Into any
agreement, partidpated in any collusion, or otherwise taken any action In restraints of free competitive
pridng 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.
19.6. Neither the entity nor" its affiliates, nor anyone associated with them, is presently suspended or
otherwise ineligible from participation in contract letting by any local, State, or Federal Agency.
19.7. Neither the entity, nor Its affiliates, nor anyone associated with them have any potential conflict
of interest due to any other dients, contracts, or property Interests for this project.
19.8. I 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.
19.9. 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.
19.10. 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 the City of Sunny Isles Beach.
mr vl~. dayol
\, W II\. 'l-
AA Print or Type Name and
Sworn to and subscribed before me this 4k day ofGv/.;1 t
~ Personally Known OR
Cl Produced Identification ; Type of Identification
. ~-
NOTARYPUBllC~
I.JJnif)
. 2001:'
PAGE 75 OF 78
SECTION 20
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.
20.1. Has you 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
x
20.2. 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 X
20.3. 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, Bid No. () 1r - LJ b - () ~ . Janitorial
Services Maintenance
~'I
. D U 1: ~ Z_
Firm
~~ 1/40/kP'
Authoriz gnature
~/6 - 2..3- o??
Date
(rJJrf'vi f/arfi4r7J'7 -~~I
Print or ype Name an Itle
END OF SECTION
PAGE 76 Of 78