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Contract Number 24-07
Date Bond Executed (Date of Contractor Later) February 5, 2024
PRINCIPAL./CONTRACTOR (Legal Name and Business Address)
PTS CONTRACTORS, INC.
4075 Eaton Road
Green Bay, WI 54311
SURETY(IES) (Legal Name(s) and Business Address(es))
LIBERTY MUTUAL INSURANCE COMPANY
175 Berkeley Street
Boston, MA 02116
OWNER (Legal Name and Business Address)
CITY OF OSHICOSH
215 Church Avenue
PO Box 1130
Oshkosh, Wisconsin 54903-1130
;=i; Q.zTY OF OSHKOSH
Type of Olgaiiizatioil
—Individual —Partnership
X Corporatiol2
State of Incorporation
Wisconsin
Penal Sum of Bond
Five Percent of Amount bid
(5%)
OBLIGATION
The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors,
and assigns to the Owner for the amount of the Penal sum identified above if the Owner accepts the bid of this
Contractor within the time specified in the Bid documents or within such time period as may be agreed upon
between the Owner and the Contractor, and the Contractor shall fail to execute the Contract within five (5) business
days of written notice to the Contractor and Surety of. Owner's intent to make a claim upon this Bond.
The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in
which the Owner may accept the Bid,
If the Contractor either enters into a contract with Owner in accordance with the terms of the Bid and gives such
bond(s) that may be specified in the Bidding documents for the faithful performance of the Contract and for the
prompt payment of labor, materials, and supplies furnished for the purpose thereof, or pays to the Owner the
difference between the amount specified in the Bid and such larger amount for whicli the Owner may in good faith
contract with another party to perform the work covered in such Bid, then the Surety and the Contractor shall have
no obligation under this Bond.
Page 1 of 2
Notice to the Contractor or Surety shall be deemed to have been given: (i) upon delivery to an officer or person
entitled to such notice, if hand delivered; or (ii) two (2) business days following deposit in the United States mail,
postage prepaid; (iii) upon delivery by a commercial carrier that will certify the date and time of delivery; or (iv)
upon transmission if by facsimile, e-mail, or other form of electronic transmission. Notices shall be provided to the
Owner, Surety, and/or Contractor at their address as specified on this Bond or to a facsimile, e-mail or other
electronic address that has been provided in writing to the other party to be used for this purpose,
The laws of the State of Wisconsin shall govern the interpretation and construction of this Bond. Winnebago
County shall be the venue for all disputes arising under this Bond, Any provision in this Bond that may conflict
with statutory or other legal requirement shall be deemed deleted herefrom and provisions conforming to the
statutory or other legal requirement shall be deemed incorporated herein.
PTS CONTRACTORS, INC.
Name of Principal/Contractor
Tit e eve C. Horn, Vice -President
LIBERTY MUTUAL INSURANCE COMPANY
Name of Surety
IN3U�,�
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Title Roxanne Jensen, Attorney -in -Fact
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Page 2of2
This Power of Attorney limits the acts of those named herein, and they have no authority to
bind the Company except in the manner and to the extent herein stated.
Liberty Liberty Mutual Insurance Company
Mutual. The Ohio Casualty Insurance Company Certificate No: 8209723.354019
West American Insurance Company
SURETY
POWER OF ATTORNEY
KNOWN ALL PERSONS BY THESE PRESENTS: That The Ohio Casually Insurance Company is a corporation duly organized under the laws of the Slate of New Hampshire, that
Liberty Mutual Insurance Company is a Corporation duly organized under the laws of the Stale of Massachusetts, and West American Insurance Company is a corporation duly organized
under the laws of the State of Indiana (herein collectively called the'Compan[W), pursuant to and by authority herein set forth, does hereby name, Constitute and appoint, Brims
Krause Kelly Cody Marc Sacia lzoxanne Jensen Trudy A Szolewski
all of the city of Milwaukee state of W I each individually if there be more than one named, its We and lawful attorney -in -fact to make,
execute, seal, acknowledge and deliver, for and on its behalf as surely and as its act and dead, any and all undertakings, bonds, recognizances and other surely obligations; in pursuance
of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper
persons.
IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed
thereto this 3rd day of April 2023
Liberty Mutual Insurance Company
Pv INSU� P�q`( INSu 0 Wsupq The Ohio Casually Insurance Company
�J °oaPORef y0 yJ 4°av°R�r p9y IT ooaPo�r y� West American Insurance Company
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Y�1912 0 oy1919�0 4 1991 0
By, 4 ,�
� * � H� * 1•� SM * *� David M. Carey, Assistant Secretary
State of PENNSYLVANIA
County of MONTGOMERY ss
On this 3rd day of April 2023 before me personally appeared David M. Carey, who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance
Company, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do, execute the foregoing instrument for the purposes
therein contained by signing on behalf of the corporations by himself as a duly authorized officer.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my notarial seal at Plymouth Meeting, Pennsylvania, on the day and year first above written,
P PASr
�' �o nwf �! commonwoailh of Pennsylvania • Notary Scat
a y Pastella, uh4c
OF Montgomery County
/!{'CL24tit N
My Commission expires March 28, 2026 By:
`p commission number 1126044
1 1SYtq Membe(,PennsylvamaAssociabonolNotones Teresa Paslella,NolaryPublic
Orq� P�9v
This Power of Attorney is made and executed pursuant to and by authority of the following Bylaws and Authorizations of The Ohio Casualty Insurance Company,
Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows:
Liberty
ARTICLE IV —OFFICERS: Section 12. Power of Attorney.
Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject to such limitation as the Chairman or the
President may prescribe, shall appoint such altomeys-in-fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, acknowledge and deliver as surety
any and all undertakings, bonds, recognizances and other surety obligations. Such altomeys-in-fact, subject to the limitations set forth in their respective powers of attorney, shall
have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so executed, such
instruments shall be as binding as if signed by the President and attested to by the Secretary, Any power or authority granted to any representative or attomey-in-fact under the
provisions of this article may be revoked at any time by the Board, the Chairman, the President or by the officer or officers granting such power or authority.
ARTICLE XIII — Execution of Contracts: Section 5. Surety Bonds and Undertakings.
Any officer of the Company authorized for that purpose in writing by the chairman or the president, and subject to such limitations as the chairman or the president may prescribe,
shall appoint such atlomeys-in-fact, as may be necessary to act in behalf of the Company to make, execute, seal, acknowledge and deliver as surely any and all undertakings,
bonds, recognizances and other surety obligations, Such attorneys -in -fact subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the
Company by their signature and execution of any such Instruments and to attach thereto the seal of the Company. When so executed such Instruments shall be as binding as if
signed by the president and attested by the secrelary.
Certificate of Designation — The President of the Company, acting pursuant to the Bylaws of the Company, authorizes David M. Carey, Assistant Secretary to appoint such attorneys -In -
fact as may be necessary to act on behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety
obligations.
Authorization — By unanimous consent of the Company's Board of Directors, the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the
Company, wherever appearing upon a certified copy of any power of attorney issued by the Company In connection with surety bonds, shall be valid and binding upon the Company with
the same force and effect as though manually affixed.
I, Renee C. Llewellyn, the undersigned, Assistant Secretary, The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company do
hereby certify that the original power of attorney of which the foregoing is a full, true and correct copy of the Power of Attorney executed by said Companies, Is in full force and effect and
has not been revoked, IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this 6 ) day of (� , 2024
P� \NS17� P�qY INgV -0, 1Nst1Rq
tiJ o°aPO�r yCs yJ o°pf0�r�2 �u4°aPo14ir %O
1912 0 1919 h 1991
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U6da y� �yNAMP6�NdL� ls��H01ANPaaa By, Renee C. Llewellyn, Assistant Secretary
LMS-12073 LMIC OCIC WAIC Muitl Co 02/21
8
o
City
of
Oshkosh
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
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,
Please review the attached Department of Workforce Development Disclosure of Ownerslip form, If Item 3 on this
Disclosure of Ownership form applies to your company, you must complete the Disclosure of Ownership form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ownership form does NOT apply to your company, you must complete the
information below and upload this page in the appropriate location on Quest V-Bid.
CERTIFICATION
I certify by my signature below that Item 3 of the attached Disclosure of Oznership form does NOT apply to my
firm, or a shareholder, officer, or partner of my finn.
Name
Steve C, Horn
Printed Name
Vice -President
Title
PTS Contractors, Inc.
Company Name
Feb, S, 2024
Date
1.•\Engineering\Tracy Taylor\Public Works Contracts\Miscellaneous\Disclosure of Ownership Form-2-1- Page 1 of 1
17.doca
City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54903-1130 http://www.cl.oshkosh.wl.us
State of Wisconsin
Department of Workforce Development
Equal Rights Division
Disclosure of Ownership
The statutory authority for the use of this form is prescribed in Sections 66.0903(12)(d), 66.0904(10)(d) and 103.49(7)(d), Wisconsin
Statutes.
The use of this form is mandatory. The penalty for failing to complete this form is prescribed in Section 103.005(12), Wisconsin
Statutes.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1) (m), Wisconsin Statutes].
(1) On the date a contractor submits a bid to or completes negotiations with a state agency, local governmental unit, or
developer, investor or owner on a project subject to Section 66,0903, 66.0904 or 103.49, Wisconsin Statutes, the
contractor shall disclose to such state agency, local governmental unit, or developer, investor or owner, the name of
any "other construction business," which the contractor, or a shareholder, officer or partner of the contractor, owns or
has owned within the preceding three (3) years.
(2) The term "other construction business" means any business engaged in the erection, construction, remodeling,
repairing, demolition, altering or painting and decorating of buildings, structures or facilities. It also means any
business engaged in supplying mineral aggregate, or hauling excavated material or spoil as provided by Sections
66.0903(3), 66.0904(2), 103.49(2) and 103.50(2), Wisconsin Statutes.
(3) This form must ONLY be filed, with the state agency project owner, local governmental unit project owner, or
developer, investor or owner of a publicly funded private construction project that will be awarding the contract, if both
(A) and (B) are met.
(A) The contractor, or a shareholder, officer or partner of the contractor:
(1) Owns at least a 25% interest in the "other construction business," indicated below, on the date the contractor
submits a bid or completes negotiations; or
(2) Has owned at least a 25% interest in the "other construction business" at any time within the preceding three
(3) years.
(B) The Wisconsin Department of Workforce Development (DWD) has determined that the "other construction
business" has failed to pay the prevailing wage rate or time and one-half the required hourly basic rate of pay, for
hours worked in excess of the prevailing hours of labor, to any employee at any time within the preceding three (3)
years.
Other Construction Business
Business Name
Street Address or P O Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
I hereby state under penalty of perjury that the information, contained in this document, is true and
accurate according to my knowledge and belief.
Print the Name of Authorized Officer
Authorized Officer Signature
Date Signed
Corporation, Partnership or Sole Proprietorship Name
Street Address or P O Box
City
State
Zip Code
If you have any questions call (608) 266-6861
ERD-7777 (R. 01/2011)
CONTRACT 24-07
ATTACHMENT A
LIST OF SUBCONTRACTORS
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the Subcontractors and the class of work to be performed by each. The
CONTRACTOR will be permitted to sublet a portion of the Contract, but shall perform with their
organization work amounting to at least thirty percent (30%) of the original Contract amount.
Work performed by the CONTRACTOR for any Bid Item that had been subcontracted will not be
included towards the thirty percent (30%) calculation.
If the CONTRACTOR shall sublet any part of this Contract, the CONTRACTOR shall be as fully
responsible to the CITY for the acts and omissions of their Subcontractor and of the persons either directly
or indirectly employed by their Subcontractor as they are by acts or omissions of persons directly
employed by themselves. All Subcontractors, if any, shall be listed u1 the spaces provided on the
Proposal Form and said list shall not be added to or altered without the written consent of the CITY.
Signed, final waivers of lien will need to be provided to the CITY prior to the release of the final retainage
to the CONTRACTOR.
When a Subcontractor and the class of work to be performed are not listed, it shall be considered that the
Bidder will perform the work themselves.
NAME OF SUBCONTRACTOR
x
�)1 5Q „�--u-
CLASS OR ITEMS OF WORK
& r";,jc /Pc"', -
PERCENT OF
CONTRACT AMOUNT
5" s- �s
I hereby certify that the use of the name(s) of the above Subcontractor(s) was with the knowledge and
consent of the said Subcontractor(s).
Sigi-i-afure of Bidder
Page 19 of 22
f j,
CONTRACT 24-07
PROPOSAL
The undersigned will begin work as specified after award of the Contract and complete as specified.
I hereby certify that all statements are made in behalf of
PTS Contractors, Inc.
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of Wisconsin
a Partnership consisting of
an individual trading as
the City of •State of
or
of
That I have examined and carefully prepared this Proposal from the Plans and Specifications and have
checked the same in detail before submitting this Proposal; that I have full authority to make such
statements and submit this Proposal in (its) (their) behalf; and that said sta VMents are true and correct.
Signature
Vice -President
(Title, if any)
Subscribed and sworn to before me this 5 day of February 20 24
F •.
• JVVV • `7_
N tary Public, or other authorized to administer N��A • �� .
• r
CD
(Bidder should not add any conditions or qualifyirig.s•tQt!iW %this Proposal as otherwise the Proposal
may be declared irregular as not being responsive to th•Adl'rtisement.)
Accompanying this Proposal is a Bid Bond in the amount of 5 % of the total amount of the Bid, as
called for in the Official Notice to Conractors.
Page 22 of 22