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RECENED
AUG 19 2074 CITY OF OSHKOSH
DEPT OF PUBLIC WORM
Contract Number 24-26 Annual Concrete Rehabilitation OSHKOSH, w1SCONSIN
Bond #474031
Date Bond Executed (Date of Contract or Later) 8/19/2024
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
Al Dix Concrete Inc
401 Gertrude St
Kaukauna, WI 54130
SURETY(IES) (Legal Name(s) and Business Address(es))
Merchants National Bonding Inc
PO Box 14498
Des Moines IA 50306-3498
OWNER (Legal Name and Business Address)
CITY OF OSHKOSH
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
5% of bid amount
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 hi the Bid documents or within such time period as may be agreed upon
between the Own -ter 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 I 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.
Title
At. 6 Cwxic� MERCHANTS NATIONAL BONDING INC_....
eip'a1/Golitrator Name of Surety
n
Title Michael L. Tiedt (Attorney 'in -Fact)
Page 2 of 2
Bond #: 474031
MERCHANT
BONDING COMPANY
POWER OF ATTORNEY
Know All Persons By These Presents, that MERCHANTS. BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.,
both being corporations of the Statat of Iowa, d/trio Mercti'snts National Indemnity Company (in:Call(ornia.on(y);(herein collectively called the
"Companies") do hereby make, constitute and appoint, Individually,
Michael L Tiedt
their true and lawful Attorneys) -in -Fact, to sign Its name as surety(les) and to execute, seal and acknowledge any and all bonds, undertakings,
contractanies In
of
persons, guaranteeing thand other e performances In -the of contracts arndiexec executbehalf of ing guaranteeing bonds and undertarbusiness of kings required guaranteeing
permitted Inthe
any actions
or proceedings allowed by law.
This.PowerofrACtomay is gtsnted:and: is signed andsealed by facsimile under and by authority of the following By-Laws:adopled,by the Board of
Directors of Merohents Bonding .company (Mutual) on.April 23; 2bii and amended August 14, 2015 and April 27, 2024;and 'adopti9d by the Board of
Directors of Martha"hts National Bonding, Inc., on October 16, 2015 and amended on April 27, 2024,
"The President, Secretary,: TteiWrAe, or'- Assiet nt Treasujer & pny*:Assistant Secrd(aty or any Vloe President shall have :power and
eulhority to eppoinf:A1tomeys4n Faot, and to authorize .them la exect'a.:on behalf of the C'6mpany, and ells"ch- the ':01 of the - .00 any thereto,
tciids ;and underi'ekingtt,'rgnizanles.; contracts of indemnity snd.other writings obligatory in the nature thereof."
"The signature ,ofiany authorized officer and �4he:seal of the C.atiapsny may be affixed by facsimile or electronic transmission to any Power of Attorney
or Cettifidation ,thereof authorizing the executlon and de(Wery: of any bond, undertaking, recognizance, or other suretyship obligations of the
Company, and such signature and seal when so used shall have the some force and effect as though manually fixed."
In connection with obligations in favor of the Florida Department of Transportation only, It Is agreed that the power and aut horlty hereby given to the
Attorney -In -Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction
contracts required by the State of Florida Department of Transportation. It Is fully understood• that consenting to the State of Florida, Department
of Transportation making payment of the final estimate to the Contractor and/or Its asslgriea, shall not relieve this surety compgtiy of any of
Its obligations under Its bond.
In connection with obligations In favor of the Kentucky Department of Highways only, It is agreed that the power and authority hereby given
to the Attorney -in -Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner -
Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation. 2024
In Witness Whereof, the Companies, have caused this Instrument to be signed and sealed this 2nd day of August ,
MERCHANTS BONDING COMPANY (MUTUAL)
MERCHANTS NATIONAL BONDING, INC.
d/bla MERCHANTS NATIONAL INDEMNITY COMPANY
2003,
By
President
STATE OF iOWA
COUNTY OF DALLAS as,
On this 2nd day of August 2024 , before me appeared Larry Taylor, to me personally known, who being by me duly sworn
did say that he Is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the
seals affixed to The foregoing Instrument are the Corporate Seals of the Companies; and that the said Instrument was signed and sealed in behalf
of the Companies by authority of their- respective Boards of Directors.
�gFLiAC�, Penni Miller
0. Commission Number 787952
i 6 My Commission Expires -.•
104fVt+ January 20, 2027 Notary Public
(Expiration of notary's commission
does not Invalidate this Instrument)
I, Elisabeth Senderafsld; Secretary of MERCHANT8 BONDING COM.P-ANY jMUTUAL) and MERCHANTS NATIONAL BONDING, INC., do
het4y okiY that ihe;A§gye and foregoing is,a true and correct copy of the POWER-0€-ATTORNEY executed; byaaid Companies,wh(ch is still
In full force and effect grid has not been amended or revoked.
In Wifnass Whereof, I have hereunto set my hand and affixed the seal of the Companies on this 2nd day of
....... .......
Secretary
933
POA 0018 (6/24)
August , 2024
RECEIVED
CONTRACT 24-26 AUG 19 2024
ATTACHMENT A
DEPT OF PUBLIC WORKS
LIST OF PROPOSED SUBCONTRACTORS OSHKOSH, WISCONSIN
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the proposed 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 from the Subcontractors 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 PROPOSED
SUBCONTRACTOR
S+nrv,,\
CLASS OR ITEMS OF WORK
PERCENT OF
CONTRACT AMOUNT
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).
/Z � . �2 '--/
Sign re of Bidder
Page 6 of 9
RECEIVED
CONTRACT 24-26
PROPOSAL
AUG 19 2024
DEPT OF PUBLIC WORKS
OSFIKOSH, WISCONSIN
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
(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 of
the City of Q,V � n �a ; State of 6mst 6
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 stat is are t e and correct.
Signature
(Title, if any)
Subscribed and sworn to before me this day of A V C� O ST 20'_.
{ TRAVIS HAEN
Notary Public, or other authorized to administer Notary Fu0c
State of Wisconsin
(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 S % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 9 of 9
city
O�
Oshkosh
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
RECEWEEt,
AUG 1 9 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
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 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
1 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.
a, Al-�
Na VA
Pri�Imo, 9� l.x
Name
f(iorl
�!� I LVA
Title
Al l k 6owe�clo:�,
Company Name
'M I I -) '4"
Date
1:\Engineering\Tracy Taylor\public Works Contracts\ Miscellaneous \ Disclosure of Ownership Form-2-1- Page 1 of 1
17.docx
City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54903-1130 http://www.ci.oshkosh.wi.us
BID BOND
RECEIVED
AUG 19 202A,
Contract Number 24-26 Annual Concrete Rehabilitation DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Date Bond Executed (Date of Contract or Later) August 19, 2024
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
Vinton Construction Company
1322 33rd Street
Two Rivers, WI 54241
SURETY(IES) (Legal Name(s) and Business Address(es))
Travelers Casually and Surety Company of America
One Tower Square
Hartford, CT 06183
OWNER (Legal Name and Business Address)
CITY OF OSHKOSH
215 Church Avenue
PO Box 1130
Oshkosh, Wisconsin 54903-1130
OBLIGATION
CITY OF OSHKOSH
Type of Organization
—Individual Partnership
X Corporation
State of Incorporation
Wisconsin
Penal Sum of Bond
Five Percent of the Amount Bid (5%)
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 Nvritten 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 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 tlus 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.
4
CU l C
Vinton Construction Company Travelers Casualty and Surety Company p y of America
Name of Principal/Contractor Name of Surety
Title MICHAEL
I�tlpnnlp
!, Rl1 C
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a
SEA,
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,7,�'•y��SCUNs���...
`rye;
0
l,,l,Ifflt!!i
IlliNt�`
Kathryn A, Weidner, Attorney -in -Fact
Page 2 of 2
Travelers Casualty and Surety Company of America
Travelers Casualty and Surety Company
TRAVELERS J St, Paul Fire and Marine Insurance Company
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That Travelers Casually and Surety Company of America, Travelers Casualty and Surety Company, and St.
Paul Fire and Marine Insurance Company are corporations duly organized under the laws of the State of Connecticut (herein collectively called the
"Companies"), and that the Companies do hereby make, constitute and appoint Kathryn A. Weidner of MADISON
Wisconsin , their true and lawful Attorney -in -Fact to sign, execute, seal and acknowledge any and all bonds, recognizances,
conditional undertakings and other writings obligatory in the nature thereof on behalf of the Companies In their business of guaranteeing the
fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any
actions or proceedings allowed by law.
IN WITNESS WHEREOF, the Companies have caused this instrument to be signed, and their corporate seals to be hereto affixed, this 17th day of January,
2019.
ks
l Virg o3y ANo
a H 41iU MUM, s t AEI
y
'� "vs r� ►N lti+
State of Connecticut
By:
City of Hartford ss, Robert L. Rane , enlor Vice President
On this the 17th day of January, 2019, before me personally appeared Robert L. Raney, who acknowledged himself to be the Senior Vice President
of Travelers Casualty and Surety Company of America, Travelers Casually and Surety Company, and St. Paul Fire and Marine Insurance Company, and
that he, as such, being authorized so to do, executed the foregoing instrument for the purposes therein contained by signing on behalf of said
Companies by himself as a duly authorized officer.
IN WITNESS WHEREOF, I hereunto set my hand and official seal. P n t
ROTARY � LJy (//•%/
My Commission expires the 30th day of June, 2021 4ja
Pe$11`� Anna P. Nowik, Notary Public
This Power of Attorney is granted under and by the authority of the following resolutions adopted by the Boards of Directors of Travelers Casualty and
Surety Company of America, Travelers Casually and Surety Company, and St. Paul Fire and Marine Insurance Company, which resolutions are now in full
force and effect, reading as follows:
RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President, any Vice President, any
Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary may appoint Attorneys -in -Fact and
Agents to act for and on behalf of the Company and may give such appointee such authority as his or her certificate of authority may prescribe to sign
with the Company's name and seal with the Company's seal bonds, recognizances, contracts of indemnity, and other writings obligatory in the nature of a
bond, recognizance, or conditional undertaking, and any of said officers or the Board of Directors at any time may remove any such appointee and revoke
the power given him or her; and it is
FURTHER RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President or any Vice
President may delegate all or any part of the foregoing authority to one or more officers or employees of this Company, provided that each such
delegation is in writing and a copy thereof is filed in the office of the Secretary; and it is
FURTHER RESOLVED, that any bond, recognizance, contract of indemnity, or writing obligatory in the nature of a bond, recognizance, or conditional
undertaking shall be valid and binding upon the Company when (a) signed by the President, any Vice Chairman, any Executive Vice President, any
Senior Vice President or any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any
Assistant Secretary and duly attested and sealed with the Company's seal by a Secretary or Assistant Secretary; or (b) duly executed (under seal, If
required) by one or more Attorneys -In -Fact and Agents pursuant to the power prescribed in his or her certificate or their certificates of authority or by one
or more Company officers pursuant to a written delegation of authority; and it is
FURTHER RESOLVED, that the signature of each of the following officers: President, any Executive Vice President, any Senior Vice President, any Vice
President, any Assistant Vice President, any Secretary, any Assistant Secretary, and the seal of the Company may be affixed by facsimile to any Power of
Attorney or to any certificate relating thereto appointing Resident Vice Presidents, Resident Assistant Secretaries or Attorneys-in-Factfor purposes only of
executing and attesting bonds and undertakings and other writings obligatory in the nature thereof, and any such Power of Attorney or certificate bearing
such facsimile signature or facsimile seal shall be valid and binding upon the Company and any such power so executed and certified by such facsimile
signature and facsimile seal shall be valid and binding on the Company in the future with respect to any bond or understanding to which it is attached.
I, Kevin E. Hughes, the undersigned, Assistant Secretary of Travelers Casualty and Surety Company of America, Travelers Casualty and Surety
Company, and St. Paul Fire and Marine Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of the Power of
Attorney executed by said Companies, which remains in full force and effect.
Dated this 19th day of August 1 2024
►x° r ,J►,IV Aro+` gon
R OONIL�. Kevin E. Hughes, Assl Cant Secretary
To verify the atithenticity oftllls Power of Attorney, please call us at 1-800-421-3880.
Please refer to the above -named Attorneydn-Fact and the detalls of the bond to which this Power of Attorney is attached.
RECEIVED
CONTRACT 24-26 AUG 19 2024
ATTACHMENT A
DEPT OF PUBLIC WORKS
LIST OF PROPOSED SUBCONTRACTORS OSHKOSH, WISCONSQV
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the proposed 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 from the Subcontractors 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 PROPOSED
SUBCONTRACTOR
if a # \L ►—
CLASS OR ITEMS OF WORK
Traf� . Co niY0 l
PERCENT OF
CONTRACT AMOUNT
2.3y'%
I hereby certify that the use of the name(s) of the aboye�Subcontractor(s) was with the knowledge and
consent of the said Subcontractor(s). -AFtUCTjO���''�.
GpRf' 0 R'q . 0
Signature of Bid Micliae . Maples s 2 �,SEAL
President '•,,� �•.,GJ�/S�ys�\�.�
,,)?age
RECEIVED
CONTRACT 24-26
PROPOSAL AUG 19 2024
EPT OF PUBLIC WORKS
The undersigned will begin work as specified after award of the Contract an-a)gQmpjeteas'(sp&Mfied.
I hereby certify that all statements are made in behalf of
Vinton Construction Company
(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 Two Rivers ; State of
Wisconsin
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 statements are ftue and �o-f l "'►►►,,,
O
S tub O
Michael J. Maples / llaes Xe t
(Title, if ariy
Subscribed and sworn to before me this 19th day of August ``,�����►���►II►i 20 24
ON
zn Qu.�,t . P,,cp--j, .
Notary A 1 c, or other authorized to administer
v'A
'- 'Y •. : _
�.OF ISO �a`•
(Bidder should not add any conditions or qualifying statements to this Proposal as�'btly�,wM1W1'e e Proposal
may be declared irregular as not being responsive to the Advertisement.)
Accompanying this Proposal is a Bid Bond in the amount of S % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 9 of 9
Cify
off
Oshkosh
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
RECENEn
AUG J92024
-pEpT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
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 0evners1dp form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ownersldp 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 070ners1iip form does NOT apply to my
firm, or a shareholder, officer, or partner of my
Name
Michael J. Maples
Printed Name
President
Title
Vinton Construction Company
Company Name
8/19/2024
Date
RU C T�
r
I ,may
z ; SEAL
71
S `c
, CO, fS��•
```,,,
is\Engineering\Tracy Taylor\Public {Yorks Contracts\Miscellaneous\Disclosure of Ownership Fonn_2-1-
17.doG
Page 1 of 1
City Hall, 215 Church Avenue P.O. Box 1 130 Oshkosh, WI 54903-1 130 http://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
N/A
Street Address or P 0 Box
City
State
Zip Code
Business Name
Street Address or P 0 Box
City
State
Zip Code
Business Name
Street Address or P 0 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
�^^"rnfn nrrnMinn fn mu knnwtndrick and hpiipf_
Print the Name of Authorized Officer `,,a,iun►n,,,,
Michael J. Maples
���.�`` �RUCTi ''�•,
Authorized Officer Signat,jfe
_
�.�` O,�'
'igned
i�i924
Cofpofation, PartnersheKole
ProprietOr Name
; b
Vinton Construction Company
a EALz
Street Address or P 0 Box
's '.� t%
�a
City
State
Zip Code
1322 33rd Street, P.O. Box 137
!�
.�`�'
Two Rivers
WI
54241
If you have'WnV,1eA'6ns call (608) 266-6861
ERD-7777 (R. 01/2011)
..........
OTM-2010
...,FAIA Document A31
nd
CQ RA010 R-r
starug and addrea)
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E7ev0t6pof& safety ong lkleMnity qbrngany
i'ffzi Cowan,. Ste 400
!tPCEIVEO
AUG 19 2024
DFPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
YFits oqd
..4rh n
danoequentat. i3onsalratidn With
an aitorriey Is 6MOragAd 'Mfh
modiricatfon.
Afty-ifribUlffrreference to.
adrytractor, Stirdt9l owrie.r or
other pdrly-1-hall be.cohsidered
plural where ppojloilsle,- .... - - - -
in OY
set ror6above, ftirtftep atoNfile
ota-boiaidtAw Ownerl iheatnotstit
OWN. an.
ab
i. `T• ohowit _�Jopwrx0- -ft*bio
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tt
4hF io.-iiject and o�i"Iseace the epta�kt'a I Owner,: the
t
t of labor And materiti(:fin-nished in the prosoouifoprosecutionthereof; or t�) pays to the Owner the
B6n4j betwoAnte.amountspNified in said and such larger amount
ad the % m0 it' thig Ai!i
Wit
for with -P.Of -W t7kl, Then a,n.6..t.b,uj.pArLy'to =0110r.- ofk.covenAby
kny notice 0.
booby *amg, f
Contractor to:&xtend this timid n.WY Waiver of
.0b) O.X�j �Ad %jWjd .4in in fWJ f eft
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ich'the OWhtr. I
J.M.:a _qtn tbid Owner stia
ty shall not.apjtany oxfensi.,aa OX0 edingsixty (60). days In
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-
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comply vhffi k staulory tit' 6diet legal rd4(4?WAt ktd 10066b df *'X' 01 'a'.
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or S. Ary ()r My Anblarit SAP .. )0
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-to any bond, v**kYwor
COM rANY
L' COMPAN)� W D 'VEL0pW.:gt,.j..RW-T -ANU IN 15111MIT - M
.IN WRNC35 WRpuQv.'C0
sigii�fta4by_&41'
rd by et
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ACKNOWLEDGEMENT'
A -nothey- p0bJ10*QrDih0r.off1v y
identity pf thtlnd(Adbal'Wh() s1gi - Iled tho. dpCOMOOM
fdtAq�e4: " "d u6t1he tfUth 00A ACOU WYi
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pdeso�pjjjq Sans 2
d before niG.g6&L.DLr n ii -fi hit aw excew-4
ba.lbis 17 . :W9
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nr
Ho"()lIYEN P. MAM
A6M.7. POD S
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rattlae Z111"Ed
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Od DEVELOPERS-SURM ANR INDEMNITY
T6 admikne4. Uble'.864" r MigiMit! SWOWY '4Sf:'Cc).REK)T?�YM:INSUPANCF--COMIIA1.4y
Chu prti#io lion is oxeauted.in th6CW'of Cl4W19nd,'0W6jffiWM41& Pi'2021
gac
POANO., NIA.
C SMS �04'i`
S19yiecVAnd:§ealed lhfi§. 16th AAY.bf Allu8t,2024
ACKNOWI,EDGMENT
I 1�g this.
-,or othot o . . d ,
officer Willp elff ' - , -
Y public 17 11 Iv
d'- Idual
verif, nly the ided. 'Of. 0 Ill. IV.
I ies 0
�60UMOnt to which this- aertlftatO is
who sl6n-ed the 8
attached, and'qpt the truthfulrT69%' :CQuraoyl'or
Lvalldit of that.
St,#6 of a., califorrila Diego
. . :fan
county of
Rebekah Earls; Notat"Y PUllc
Wore mai
on - AUG- r)
(Inqert.name andlITWOM0 Office:
Mart�sa-
-po,rsanajjy--qppesr6d, the who.s0'-naM-eW IsMre
me: t�o ba a A
execi�fied the who-prov6dw. to: helsheAbley
�so �. 6ment -arv-d:a0knoWedg*ed W"
.ou t1bed to the-,,w inqtr : -p . . .. - -)on, the nt �lt h 'Instwme the
his/herlthe
and by ..
fill.�lhi6r/th6ir,�a6thorized capadity(iEl.a) exceptedtheihWuMorit,
or fh6 of Whio-h-thO POMM(i) -0.6fed, 0-
W�
pers.6h 0 fhe foTeg6lng
T. ertlfy 'r-EN4TY OF PERJURY:UnderAho jaWsdf the. State of Callf6rola.-th.
paragraph it troio..4nd 000t..
REBEKAH BADS
ss
me
Houry
WITNESS my. hand. and officlat 'Beal San Diego WOW commission * 246640
3
W 9, 2Oi7
- slo ryl8lturo
itECEIVED
CONTRACT 24-26 AUG 19 2024
ATTACHMENT A DEPT of PUBLIC WORKS
OSHKOSH, WISCONSIN
LIST OF PROPOSED 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 proposed 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 from the Subcontractors 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 PROPOSED
SUBCONTRACTOR
PERCENT OF
CLASS OR ITEMS OF WORK 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).
Signatu of Bidder
Page 6 of 9
RECEIVEI>
CONTRACT 24-26
PROPOSAL AUG :'t .9 207A
r ified.
The undersigned will begin work as specified after award of the Contract an �&rii�l' te,fas spar .
I hereby certify that all statements are made in behalf of
&eaq-f S '
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of 0' l S C-JnA. g 1 rU
a Partnership consisting of rT or
an individual trading as , of
the City of R Ci C-1 State of ra C. S t '�'j
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 statements are true and correct.
`1%%IIIirrrrI, /�xoo��
Q� atare
Q���.
t
( i le, if any)
frrrriii�ti��
Subscribed and sworn to before me this _ day of 120—
Notary Public, or other authorized to administer
(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 _A�_ % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 9 of 9
RECEIVED
AUG 19 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
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 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 Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
4Nam
Printed Name
Title
Company Name
1;\ Engineering\Tracy'faylor\Public Works Contracts\Miscellaneous\Disclosure of ownership Furma-1- Page 1 of 1
17.docx
City Hall, 215 Church Avenue P.O. Box 1130 Oshkosh, WI 54.903-1130 http://www.Ci.oshkosh.wi.us
State of Wisconsin Disclosure Of �Wllet'Siiiip
Department of Workforce Development
Equal Rights Division
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,
n+hAr rnnstruction Business
I hereby state under penalty of perjury inai ine fnivn1iauv1I, l.VIILGIJI1�.A-
accurate according to my knowledge and belief.
Print the Name of Authorized Officer
Officer Signature
Corporation, Partnership or Sole
Address or P O
Date
p Name
City I State ` Zip
ERD-7777 (R. 0112011)
If you have any questions call (608) 266-6861
RECEIVED
C
AUG �� 9 2U24� ITY OF OSHKOSH
DEPT OF PUBLIC WORKS
Contract Number 24-26, Annual Concrete Rehabilitation OSHKOSH, WISCONSIN
Date Bond Executed (Date of Contract or Later) August 19, 2024
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
LaLonde Contractors, Inc.
1609 Lincoln Avenue
Waukesha, WI 53186
SURETY(IES) (Legal Name(s) and Business Address(es))
Swiss Re Corporate Solutions America Insurance Corporation
1200 Main Street, Suite 800
Kansas City, MO 64105
OWNER (Legal Name and Business Address)
CITY OF OSHKOSH
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 Amount Bid (5%)
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 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 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.
LaLonde Contractors, Inc.
Name of Principal/Contractor
Title Mark aLonde resi nt & Secretary
pNT RA
To a
\t U \L A dJ \ J
798
�/SOO• - s
N
Swiss Re Corporate Solutions America Insurance Corporation NSax,F C4
Name of Surety S E A L'
gi
. M 1973�
Title Jenri t, Hirth, Attorney -in -Fact
Page 2 of 2
SWISS RE CORPORATE SOLUTIONS
SWISS RE CORPORATE SOLUTIONS AMERICA INSURANCE CORPORATION ("SRCSAIC")
SWISS RE CORPORATE SOLUTIONS PREMIER INSURANCE CORPORATION ("SRCSPIC")
W ESTPORT INSURANCE CORPORATION ("WIC")
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, THAT SRCSAIC, a corporation duly organized and existing under laws of the State of Missouri, and
having its principal office in the City of Kansas City, Missouri, and SRCSPIC, a corporation organized and existing under the laws of the State of
Missouri and having its principal office in the City of Kansas City, Missouri, and WIC, organized under the laws of the State of Missouri, and having its
principal office in the City of Kansas City, Missouri, each does hereby make, constitute and appoint:
PATRICK A. MCKENNA, JAY A. ZAHN, JENNY L. HIRTH, KATHRYN A. WEIDNER,
and LYNN E. POTTER
JOINTLY OR SEVERALLY
its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings
obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by
law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the
amount of:
FIFTY MILLION ($50,000,000.00) DOLLARS
This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of
Directors of both SRCSAIC and SRCSPIC at meetings duly called and held on the I8th of November 2021 and WIC by written consent of its
Executive Committee dated July 18, 2011.
"RESOLVED, that any two of the President, any Managing Director, any Senior Vice President, any Vice President, the Secretary or any Assistant
Secretary be, and each or any of them hereby is, authorized to execute a Power of Attorney qualifying the attorney named in the given Power of
Attorney to execute on behalf of the Corporation bonds, undertakings and all contracts of surety, and that each or any of them hereby is authorized to
attest to the execution of any such Power of Attorney and to attach therein the seal of the Corporation; and it is
FURTHER RESOLVED, that the signature of such officers and the seal of the Corporation may be affixed to any such Power of Attorney or to
any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be
binding upon the Corporation when so affixed and in the future with regard to anv bond, undertaking or contract of surety to which it is attached."
qi5 AVER, ""+NS PAEAP'
Sip ORilys%, �c`hO� �PPOBy
Rgr,:Ys y y
ErikJanssens, Senior Vice Precedent of SRCSAIC &Senior Vice President h. €j}
3 = , M : ofSRCSq,PIC & Senior Vice President of �VEC r '}—
1973 'ah
.d 9 \yyba' dt ti/Sgp�f
f .... p�y�o ` By
''"74f? +N„+` Gerald Jagrowski, Vice President of SRCSAIC& Vice President ofSRCSPIC
& Vice Presideut of wiC
IN WITNESS WHEREOF, SRCSAIC, SRCSPIC, and WIC have caused their official seals to be hereunto affixed, and these presents to be signed by their
authorized officers
this 28TH day of MARCH 20 24
Swiss Re Corporate Solutions America Insurance Corporation
State of Illinois Swiss Re Corporate Solutions Premier Insurance Corporation
County of Cook Westport Insurance Corporation
On this 28TH day of MARCH 20 24 before me, a Notary Public personally appeared Erik Janssens , Senior Vice President of SRCSAIC
and Senior Vice President of SRCSPIC and Senior Vice President of WIC and Gerald Jagrowski , Vice President of SRCSAIC and Vice President of
SPCSPIC and Vice President of WIC, personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney
as officers of and acknowledged said instrument to be the voluntary act and deed of their respective companies.
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I, Jeffrey Goldberg, the duly elected Senior Vice President and Assistant Secretary of SRCSAIC and SRCSPIC and WIC, do hereby certify that the above and
foregoing is a true and correct copy of a Power of Attorney given by said SRCSAIC and SRCSPIC and WIC, which is still in full force and effect.
IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 19th day of August , 2024 .
Jeffrey Goldberg, Senior Vice President &
Assistant Secretary of SRCSAIC and
SRCSPIC and WIC
RECEIVE!)
CONTRACT 24-26 AUG 19 2024
ATTACHMENT A DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
LIST OF PROPOSED 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 proposed 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 from the Subcontractors 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 PROPOSED
SUBCONTRACTOR
Northeast Asphalt
Fox River Landscape
Hard Rock Sawing
PERCENT OF
CLASS OR ITEMS OF WORK CONTRACT AMOUNT
Asphalt 1.78%
Erosion Control / Restoration 1.20%
Pavement Sawing 2.00%
0.00%
0.00%
0.00%
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).
ftwi �� (Electronically
Signed)
Signature of Bidder Mark LaLonde
President & Secretary
Page 6 of 9
RECEIVED
CONTRACT 24-26 AUG 19 2024
PROPOSAL
DEPT OF PUBLIC WORK:
OSHKOSH, WISCONSIN
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
LaLonde 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 ; or
an individual trading as ; of
the City of Waukesha ; State of Wisconsin
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 statements e rue rect.
TRACT'%
OR
c,Z� OAP 9� OWN Mark LaL nde gna re
SEAL,,'8 =
President and Secretary
9 a (Title, if any)
/SCONA'E �
Subscribed and sworn to before me this 19th day of August 20 24
�00RE
v pTA,4
otary Pu lic, or other autfi rized to administer }'
N AUB0 :
IR
(Bidder should not add any conditions or qualifying statements t6'klg� ,gsafs 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 5.0 % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 9 of 9
City
04frw
Oshkosh
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
RECEWEI)
AUG 1 9 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
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 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 Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
Mark LaLonde
Printed Name
President & Secretary
Title
LaLonde Contractors, Inc.
Company Name
August 19, 2024
Date
1: \ Engineering\Tracy Taylor\ Public Works Contracts\ Miscellaneous\ Disclosure of Ownership Form_2-1-
17.docX
City Hall, 215 Church Avenue P.O. Box 1 130 Oshkosh, WI 54903-1 130 http://www.ci.oshkosh.wi.us
Page 1 of 1
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
NONE.
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 knowled a and belief.
Print the Name of Authorized Officer
Mark LaLonde, President & Secretary
Authorized Officer Signature Date Signed
August 19 2024
Corporation, Partnership or Sole Proprietorship Name
LaLonde Contractors Inc.
Street Address or P O Box City State Zip Code
1609 Lincoln Avenue Waukesha WI 53186
If you have any questions call (608) 266-6861
ERD-7777 (R. 01/2011)