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HomeMy WebLinkAbout24-06 Jim Fischer IncSurety Bond No. N/A 13 �6 0 CITY OF OSHKOSH Contract Number CITY CONTRACT 24-06 - CONCRETE SIDEWALK (NEW AND REHABILITATION) Date Bond Executed (Date of Contract or Later) January 1 5, 2024 PRINCIPAL/CONTRACTOR (Legal Name and Business Address) Jim Fischer, Inc. 2605 S Casaloma Drive Appleton, WT 54912 SURSTY(IES) (regal Name(s) and Business Addresses)) United Fire & Casualty Company PO BOX 73909 CEDAR RAPIDS, IA 52407 OWNER (Legal Name and Business Address) CITY OF OSHKOSI-I 215 Church Avenue PO Box 1130 Oshkosh, Wisconsin 54903-1130 OBLIGATION Type of Organization ____Individual. Partnership .X Corporation State of Incorporation Wisconsin Penal Sum of Bond Five Percent of the Attached Bid (5% of the Attached Bid) The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administxators, 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 which 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 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. Jim Fischer, Inc.United Fire & Casualty Company Name of Principal/Contractor Name of Surety itie / Titie J a orriay-in-Fact CM JPiIry _. It. Page 2 of 2 UNITED FIRE & CASUALTY COMPANY, CEDAR RAPIDS, iA Inquiries: Surety Department ufglfi FINANCIAL PACIFIC INSURANCE. COMPANY, LOS ANGELES, CA Cedar Rapids, IA 52401 UNITED FIRE & INDEMNITY COMPANY, WEBSTER, TX 118 Second Ave SE CERTIFIED COPY OF POWER OF ATTORNEY (original on File at Home Office of Company — See Certification) KNOW ALL PERSONS BY THESE PRESENTS, That United Fire & Casualty Company, a corporation duly organized and existing under the laws of the Slate of Iowa; United Fire & Indemnity Company, a corporation duty organized and existing under the laws of the State of Texas; and Financial Pacific Insurance Company, a corporation duly organized and existing under the laws of the State of California (herein collectively called the Companies), and having their corporate headquarters in Cedar Rapids, State of Iowa, does make, constitute and appoint SHANE LARSON, TODD LOOKER, JONATHAN L UCAS, EACH INDIVIDUALLY their true and lawffil Attomey(s)-in-Fact with power and authority hereby conferred to sign, seal and execute in its behalf all lawfill bonds, undertakings and other obligatO i Y instruments of similar nature provided that no single obligation shall exceed $25 , 000 , 000.00 and to bind the Companies thereby as frilly and to the same extent as If such instnunents were signed by the duly authorized officers of the Companies and all of the acts of said Attorney, pursuant to the authority hereby given and hereby ratified and confirmed. The Authority hereby granted shall expire the lst day of October, 2025 tint ess sooner revoked by United Fire & Casualty Company, United Fire & Indemnity Company, and Financial Pacific Insurance Company. This Power of Attorney is made and executed pursuant to and by authority of the following bylaw duly adopted by the Boards of Directors of I .Inited Fire & Casualty Company, United Fire & Inclelnnity Company, and Financial Pacific Insurance Company, "Article Vi— Surety Bonds and Undertakings" Section 2, Appointment of Attomey-in-Faet. "The President or any Vice President, or any other oftieer of the Companies may, from time to time, appoint by written certificates attorneys-in-faet to act in behalf of the Companies in the execution of policies of insurance, bonds, undenakings and other obligatOlY instruments of like nature, The signature of any officer authorized hereby, and the Corporate seal, may be affixed by facsimile to any power of attorney or special power of attorney or certification of either authorized hereby; such signature and seal, when so used, being adopted by the Companies as the otiginal signature of such officer and the original seal of the Companies, to be valid and binding upon the Companies with the same force and effect as though manually affixed, Such attrnneys-in-fact, subject to the limitations set of forth in their respective cenificates at' authority shall have till power to bind the Companies by their signature and execution of any such insmnnents and to attach the seal the Companies thereto, The President or any Vice President, the Board of Directors or any other officer of the Companies may at any time revoke all power and authority previously given to any attomey-in-fact, OF, the NIES have ,�:N C' l %HQrQ11 �'11" "$"q%"'4t I resiciet�aztclSitsy �L��tte seal to be he eto affixed thiscl st daycaused of Octoberb 2signed by its vice t4 caa�Q+T RArx x -,: ��i� - UNITED FIRE & CASUALTY COMPANY sr�r° r� lob6 UNITED FIRE & INDEMNITY COMPANY FINANCIAL PACIFIC INSURANCE CONWANY /pg1AK 11111d���„'plli!�inu����` Iflltlf!!.��� By State of Iowa, County of Linn, ss: Vice President On I st day of October, 2028, before me personally came Kyanna M. Saylor to me known, who being by me duly swom, did depose and say; that she resides Cedar Rapids, State of Iowa-, that she is a Vice President of United Fire & Casualty Company, a Vice President of United Fire & Indemnity Company, and a Vice President of Financial Pacific Insurance Company the corporations described in and which executed the above instrument; that she knows the seal of said corporations; that the seal affixed to the said instrument is such corporate seal; that it was so affixed pursuant to authority given by the Board of Directors of said comorations and that she signed her name thereto pursuant to like authority, and acknowledges same to be the act and deed of said corporations. Palli Waddell I Wad&& Iowa Notarial Seal Commission number 713274 tom" NNotary Public My Conunissioo Expires 10/26/2025 My commission expires: 10/26/2025 I, Mazy A. Bertsch, Assistant Secretary of United Fire & Casualty Company and Assistant Secretary of United Fire & Indemnity Company, and Assistant Secretary of Financial Pacific Insurance Company, do hereby certify that I have compared the foregoing copy of the Power of Attorney and affidavit, and the copy of the Section of the bylaws and resolutions of said Corporations as set forth in said Power of Attorney, with the ORIGINALS ON FILE IN THE. HOME OFFICE OF SAID CORPORATIONS, and that the same are con-ect transcripts thereof, and of the whole of the said originals, and that the said flower of Attomey has not been revoked and is now in frill force and effect. In testimony whereof I have hereunto subscribed my name and affixed the corporate seal of the said Corporations this 15th day of January , 20 24 i Document A31 OTM 2010 CONTRACTOR: (Nalne, legal status and address) Jim Fischer, Inc, 2605 S. Casaloma Drive Appleton, WI 54912 OWNER: (Marne, legal status atfd addr(,ss) City of Oshkosh 215 Church Avenue Oshkosh, WI 54903 BOND AMOUNT: $ Five Percent of the attached bid PROJECT: (Maine, loaatioa orat(tlrexy, and Project niftabar, if arty) Concrete Sidewalk - Neva& Rehabilitation 24»06 Bond Ntiift6f<:NiR 1X, :€ j art SURETY: (Name, legal status and principal place of business) United Fire & Casualty Company P.O. Box 73909 Cedar Rapids, IA 52407 The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment Of which the Contra, ctor.tind Surety bind themselves, their heirs, executors, administrators, successors and assigil<s, jointly and severalty, as provided herein. The conditions of this Bond are such that if the Owner accepts the bid of the Contractor within the time specified in the bid documents, or within such time period as may be agreed to by the Owner and Contractor, and the Contractor either (1) enters into a contract with. the Owner in accordance with the terms of such bid, and gives such bond or bonds as may be specified in the bidding or Contract Documents, with a surety admitted in the jurisdiction of the Project and otherwise acceptable to the Owner, for the faithful performance of such Contract and for the prompt payment of labor and material furnished in the prosecution thereof; or (2) pays to the Owner the difference, not to exceed the amount of this Bond, between the amount specified in said bid and such larger amount for which the Owner may in good faith contract with another party to perform the work cowered by said bid, then (hisobligation shall be null and void, otllcrlvise to remain in frill force and effect. 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. Waiver of notice by the Surety shall not apply to any extension exceeding sixty (60) days in the aggkegate beyond the time for acceptance of bids specified in the bid documents, and the Owner and Contractor shall obtain the Surety's consent for an extension beyond sixty (60) days. If this Bond is issued in connection with a subcontractor's bid to a Contractor, die term Contractor in this Bond shall be deemed to be Subcontractor and the term Owner shall be deemed to be Contractor. When this Bond lists been i trnished to comply Nvith a statutory or Other legal requirement in the location of the project, any provision in this Bond conflicting with said statutory or legal requirement shall be deemed deleted herefrom and proVigionq col forming to such statutory or other toga] requirement shall be deemed incorporated herein. When so` rurnished; the inwritis that this Bond shall be construed as a statutory bond and not ns a common law bond. ADDITIONS AND DELETIONS: The author of this document ties added information needed for its completion. The author may also have revised the text of the original AIA standard form. An Additions and Deletions Report that notes added Information as well as revisions to the standard form text is available from the author and should be reviewed. A vertical line in the left margin of this document indicates where the author has added necessary Information and where the author has added to or deleted from the original AIA text. This document has important legal consequences. Consultation with an attorney is encouraged with respect to its completion or modification. Any singular reference to Contractor, Surety, Owner or other party shall be considered plural where applicable. Init, AIA Document A310TM — 2010, Copyright ©1963, 1970 and 2010 by The American Institute of Architects. All rights reserved. WARNING: This AIA' Document Is protected by U,S. Copyright Law and International Trestles. Unauthorized reproduction or distribution of this AIA10 Document, or any portion of it, may result In severe civil and criminal penalties, and will be prosocutod to the maximum extent possible under the law. This document 1 was produced by AIA software at on under Order No, which expires on and is not for resale. User Notas; (369ADA17) Signed and sealed this 15th day of January , 2024 �. (t✓citttt' ctrzr'try 'rinc�Firt!) eat (YPit%i.$) (Ti jookian Lucas, Attomey-In-Fact rpt4, 5 p , ' CONR)RATE �6 J+nrrry ]t048 U ?fihP11y5t ��� geySi ai init AIA document A310TM — 2010. Copyright O 1963, 1970 and 2010 by The American Institute of Architects. All rights reserved. WARNING: This AIAo Document Is protected by U.S, Copyright Law and Intornational Treaties. Unauthorized reproduction or distribution of this AIA* Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document / was produced by AIA software at on under Order No. which expires on 02t1612018, and is not for resale. User Notes: (399ADA17) A UNITED FIRE & CASUALTY COic•IPANY, CEDAR RAPIDS, iA Inquiries: Surety Department Uf9 UNITED FIRE &. INDEMNITY COMPANY, WEBSTER, TX 118 Second Ave SE FINANCIAL PACIFIC INSURANCE COMPANY, LOS ANGELES, CA Cedar Rapids, IA 52401 INSURANCE CERTIFIED COPY OF POWER OF ATTORNEY (original on rife at I -tome Office of Company -- See Certification) KNOW ALL PERSONS BY TI•IFSE PRESENTS, Tlial United Fire & Casualty Company, a corporation duly organized and existing under the laws ol, Ile State of, town; 1,,11ulei Fire;t IndenartiIN coliipany,.a cotporation duly organized and existing under the laws of the State of Texas; and Fiitaneiat P Y61-1c (nsurance Company, a eorporatiorl duly organized and uxis(ntb tnidei• tn: laws of tlic State or California (h.ereiti collectively called the Conipanics), uIld having their corton7te headquoi'ters in Cedar' Rapids, State of loiva, does make, constitute and appoint SHANE LARSON, TODD LOOKER, JONATHAN LUCAS, EACH INDIVIDUALLY their true and llwlul Attoruey(s)-in-Ftref with power and authority hereby 'conleu•ed to si�111, seal and execute ill its behalf all lawful bonds, undertakings and other obligatlly inswullents ofsiniilar,liature j tiwided (hat no single oblieatii}u shall exceed $25,000,000,00 and to built the Companies thereby as Bully and to tie same extent his if:slich insituiilents Were siLnied by llie ditty authorized officers of the Conipaaies and all of the acts ol'said Attoniey, putsuaat (o die authority hereby given and hereby ratified and coalinited, The Autliorily hereby grouted shaft expire die 1st day of October, 2025 unless sooner revoked by United Fire & Casualty Company, United Fire & hidernnity Conhpany, and Financial Pacific Insurance Company, This Power of Attonicy is made rind executed pursuant to and by authority of the following bylaw duly adopted by die Boards of Directors of United Fire & Casualty Conilinny, United Fire &, lndeniuit}• Ctutlpmly, alit] Filiali ial Pacific Insurance Company, "Artfelc VI — Sus'ah' Bonds nnl Uuiertakings" Se, Lion 2,. Appolmliiew nl Aitomoy-m-tact, "The Ple•ident of ally Vice Presi lelit, Or ally Other otrwur of the Coltiponies may, from tittle to: little, appoitlt it {,'17IIL'It ccrlifi aleti attollleyv-ill-raet to .let ill behalf of the C',oniilailte?4s in the eloailibrl of pollCiLS ol*imuraiee, lttmk, Uadt!'itnjaitgS titid Other obligatory ills alntcllt f. Qrfl a liaittre, 11iu stt,natwe of any officer mithotized herally, and the Coiporate ,enl,mtay be affixed, by raesimf le to airy power ¢f onnrney (it'tipccinl }jdsvOr.oi`auoutcy or ecrufivatioii of either aPtholized hereby such siguaituu and will, When ;o us,0, bcritig adopted by the Compalric, rr The original siguanuu of stiah off eer and the piigivaf seal of:the C otilpanies, to he valid aad bhtdiagr illoit the Companies with ills salve ford alid efl'ecl as though manually affixed, '$Lich utttlineys in -foci, subject; to lilt- limitations set of (0i'Llt ill their n ktiuCtn,e C'Mifientos of out drily shall bone AM Ixlwerto Wild rite Coilipaui'es by their Sigiulaire aunt execution's f m)y inch inctrumaalr; mud it, rittach the seal the lompaliies thuieio. Ttte Ne ideni er wily yme President, the 13oarrl ol'Direoors or ally other officer of the Courpnnies may at any time revoke all power and authority pruyiou.lygiveu to ally attanluy-in�fnct. ,,,1,,,,,- IN WITNESS WHEREO , the COMPANIES have each caused these presents to be signed by its \J1\ttfl// `\S11l1lnlVtitl/q t11111U1111� °"P"\;, ln°ea vice president and its corporate seal to be hereto ar xed this 1st day of October, 2023 �. goo ¢eGgP)K)r4�M ti, tionPOtGLiE a 4 coRVATl< .b OR_ ` ,uLYza U`•ib� UNITED FIRE & CASUALTY COMPANY SEAL UNITED FIRE & INDEMNITY COMPANY ......�,c". FINANCIAL PACIFIC', INSURANCE COIvfPANY r too, 00 By: State of lowa, County of Lion, ss: `` Vice President On ist day of October, 2023, before me personally came Kyanna M. Saylor to me known, wile beuig by rile duly sworn, slid "depose Ind say; that she,resides in Cedar Rapids, State of Iowa; that she is a Vice President of United Fire & Casualty Company, to trice Presidenn of United Fire & Indenuhily Company, and a Vice President of Financial Pacific Insurance Company die corporations described in and which executed die above itistntnient; that she knows the seal of said corporations; that the seal affixed to die said instntnhent is such corporate seal; that it was so affixed pursuant to auhhority given by die Board of Directors of said corporations and that site signed lien Warne theretopursuant to like authorit}, and acknowledges sanhe to be the act and deed of said corporations. 1*1 PaWaddell N Iowa Notarial Commfsslvn numberer713274 IM Commission Expires 10/26/2026 Notary Public My conunission expires: 10/26/2025 1, Mary A, Berisch; Assislant Secretary of I failed Fire & Casualty Company and Assistail t Secretory of United Fire & hidou ilit}° Conipatty, and Assislafll Secretary of Financial Pacific Itstuonce Company„do hereby certify that have coinprti'ed the foregoinw copy oi'tiie Power of A(tonie), and affidavit, and ilie copy of the Section of the bylaws and resolutions of said Cotporatiolls as set forth in saidPower of Attorney, with die ORIGINALS ON FILE IN Ti-{E. HOME OFFICE OF SAID CORPORATIONS,.and, that the saute ai•ecorrect transcripts hereof, and of The whole of t t: solid originals, and,that the said ]tower ofAttomey has no( been revoked rind is now in full force and effect, Ill lestjniony wilereol'I have hereunto subscribed iuy padre and affixed die corporate seal of die said Corporations this 7.5th day of Junutiry 2024 \\\„ 1ptllllb4) {uu,Uu,n 1V41gt Ii, ,, yC sitttrj/!�. \n, or, i/y �pp.l tSUry /w t2 .° +'a � vonil4 ` t CoR1 Y it STE h y4 t1117'.0.ATa ? 2 � � jeLY 1= � y E.. SEAL Y � SEAL , ...... t11R,1,i\ 13POA0045 122017 By: ` 1 � �� U A 3J'h Assistant Secretary, OF&C & OF&I & FPiC CONTRACT 24-06 PROPOSAL �_� Y, I K 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 Ua';� Fj-,s-c&,4- (Name of Corporation, Partnership, or Person Submitting Bid) a corporation organized and existing under the laws of the State of a Partnership consisting of or an individual trading as r of r the City of ;State 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 tha cl statements and correct. Signature ELIZBETH A. WALLACENotary Publicate of Wisconsin (Title, if any) ex�►vrs 0�—/101Zu-�? Subscribed and sworn to before me this _ 0 day of Ot 0, c t 6L 20�. 1--9 Public or other authorized to administer Y (Bidder should not add any conditions or qualifying statements to this Proposal as otherwise the Proposal may be declared irregular as not being responsive to the Advertisement.) Accompanying this Proposal is a Bid Bond in the amount of j % of the total amount of the Bid, as called for in the Official Notice to Contractors. Page 10 of 10 v< I 'V M ill" 1-3 ), W TO: ALL CONTRACTORS FROM: ENGINEERING DIVISION OF CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS SUBJECT: DISCLOSURE, OF OWNERSHIP FORM Please review the attached Department of Workforce Development Disclosure of Ownership form. If Item 3 on this Disclosure of Ownership form applies to your company, you must complete the Disclosure of Ownership form arid 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 Ownership form does NOT apply to my firm, or a shareholder, officer, or partner of my firm. Nan Dq�ci-(\ 00\'— Print d Name 'Y ce�j Title '41 D IX Company Name Dat City Hall, 215 Church Avenue P.O. Box 11,10 Oshkosh, WI 54903-1130 http://www.ci.oshkosh.wi.ti.s Page I of I 3l . CONTRACT 24-06 ATTACHMENT A LIST OF SUBCONTRACTORS Pursuant to Section 66.24(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 in 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 C} ?0t-) S CLASS OR ITEMS OF WORK a N_ PERCENT OF CONTRACT AMOUNT 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). iignatu of Bidder Page 7 of 10 IRE aim I City of Oshkosh TO: ALL CONTRACTORS FROM: ENGINEERING DIVISION OF CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS SUBJECT: DISCLOSURE OF OWNERSHIP FORM �t t f"i,i ; j` i'I_ Please review the attached Department of Workforce Development Disclosure of Ouliiership form. If Item 3 on this Disclosure of Ozvnerslrip form applies to your company, you must complete the Disclosure of Ozonersitip 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-Sid. CERTIFICATION I certify by my signature below that Item 3 of the attached Disclosure. of Ownership form does NOT apply to my firm, or a shareholder, officer, or partner of my firm. Printed Name Title C-)1 iy1 f i �� Company Name Date i s I Enginocring l'! racy "1'aglur \ Vuhl is Works Cnn t rae t> 1 \ 85cc1lancu us \ D i>elosu rc of 0%voorsh ip Form_ 2.1 17.duc, Page .t of L City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54903-1130 hitp://www,ci.oshkosh.wi,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 0 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 uthor ed Off ^r Sign`ture Date Signed — AG '2-6Z gorpor tion, Partnership or Sole Proprietorship Name Street Address or P 0 Box 11 S� a S >a � fir, _ _. City 1_ h State Gu( Zip Code _ If you have any questions call (608;166-6861 PDn_7777 m nvon+1i CONTRACT 24-06 ATTACHMENT A ,a Woi 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 in 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 CLASS OR ITEMS OF WORK T PERCENT OF CONTRACT AMOUNT 12 1)10 I hereby certify that the use of the name(s) of the above Subcontractor(s) was with the knowledge and Page 7 of 10