ATTACHMENT 5 BID/BIDDER CERTIFICATION SHEET

Invitation For Bid IFB Number 04A541 l

Page 1 of 2

Only an individual who is authorized to bind the bidding firm contractually shall sign the Bid/Bidder Certification Sheet. The signature must indicate the title or position that the individual holds in the firm. This Bid/Bidder Certification Sheet must be signed and returned along with all "required attachments" as an entire package with original signatures. The bid must be transmitted in a sealed envelope in accordance with lFB instructions.

A. Our all-inclusive bid is submitted in a sealed envelope marked "Bid Submittal - Do Not Open". B. All required attachments are included with this certification sheet. C. I have read and understand the DVBE participation requirements and have included documentation

demonstrating that J have met the participation goals. D. The signature affixed hereon and dated certifies compliance with all the requirements of this bid document. The

signature below authorizes the verification of this certification. E. The signature and date affixed hereon certifies that this bid is a firm offer for a 90-day period.

An Unsigned Bid/Bidder Certification Sheet May Be Cause for Bid Rejection

1. Company Name

2b. Email Address q " \.,vv',->

3. Address °?-0~ ~o 'lO l l, "\ Sc&» t>~><uv\. Pr\l~ Wev:,-l-

2. Telephone Number

(101 t,ci~.....- ()'2-0"\ 2a. Fax Number

(701 t ,~ ---~~~~

Indicate your organization type: 4. D Sole Proprietorship I 5. D Partnership I 6. ~ orporation

Indicate the applicable employee and/or corporation number: 7. Federal Employee ID No. (FEIN) 2, 3>,.... l O l O 'f O (;,

Indicate the Department of Industrial Relations information: 9. Contractor Registration Number

Indicate applicable license and/or certification information: I 0. Contractor's State Licensing

Board Number Ebo ct O ~ §

12. Bidder' Name (Print)

µ ·, ,H.1\ (Q 01. r---v~

14. Signature

I 8. California Corporation No. ~,l 1 B 5B B

foooo l?;S-e3

11. PUC License Number CAL-T-

13. Title

? \ €,£> ~ 6 v.,L--\-15. Date

D~ 2-- 1 '"lO I 8 16. Are you certified with he Department of General Services, Office of Small Bus ness and Disabled Veteran Business Enterprise Services (OSDS) as: _ / a. Small Business Enterprise Yes [B" No D b. Disabled Veteran Business Enterprise Yes D No -621 If yes, enter certification number: If yes, enter your service code below:

NOTE: A copy of your Certification is required to be included if either of the above items is checked "Yes".

Date application was submitted to OSDS, if an application is pending:

17. Are you a No_9,,Small Business committing to the use of25% Certified Small Business Subcontractor Participation? Yes D No ~

If Yes, complete and return the Bidder Declaration form, GSPD-05-105 with your bid.

Invitation For Bid IFB Number 04A5411

Pagel of 1

STATEOFCALIFORNIA · DEPARTMENTOFTRANSPORTATION

BID PROPOSAL ATTACHMENT 1 ADM-1412 (REV. 11/2015)

CONTRACTOR' S NAME (Please Print):

Q,i I ''·lv Co,,~t-rC1LL-+-~ i'l . ( 1'1.l. CONTRACT NO. 0 tfq, S'f JI

2

3

4

5

6

7

ESTIMATED UNIT OF ITEM QUANTITY MEASURE NO.

ITEM _,,.-

UNIT PRICE ( Price Per Unit of

Meas_ur_e

TOTAL (Estimated Quantity X Unit

Price

Each Remove and dispose old attenuator and install new Smart Cushion attenuator at the I Northbound Highway (Hwy) 880 at Market off-ramp as described in Exhibit A, Scope of $ ~ i

I lf O O 0~ I $ ft, <.f, L{ 06 ~

Work (SOW)

Each

Each

Each

Each

Remove and dispose old attenuator and install new Smart Cushion attenuator at the Eastbound Highway (Hwy) 580 at Strobridge off-ramp as described in Exhibit A, SOW

Remove and dispose old attenuator and install new Smart Cushion attenuator at the Eastbound Highway (Hwy) 92 at Hesperian off-ramp as described in Exhibit A, SOW

Remove and dispose old attenuator and install new Smart Cushion attenuator at the Westbound Highway (Hwy) 580 at Central off-ramp as described in Exhibit A, SOW

Remove and dispose old attenuator and install new Smart Cushion attenuator at the Eastbound Highway (Hwy) 580 at Central off-ramp as described in Exhibit A, SOW

$ <o'-f, tfool'~ ,1 $ 0~1.<.foo ~

$ ~4, '-foo 6~I $ Glfc '-fDo~

$ b~, Lfoo ~ t $ (clf,~oo-~

$ f,lf, 4oo~ : $ fc,lf t (.foo ~

SUBTOTAL (Add Line Items I through 5) I $ 3 2. 21 0 C>O ~ Projected Parts/Materials/Supplies

Calculate 10% of the Subtotal above (Subtotal X 10% = amount) Actual costs for parts/materials/supplies will be reimbursed without additional allowance for mark-up based on submitted original receipts and/or invoices approved by the Caltrans Contract Manager - See Exhibit B, Item 5

100 Per hour Traffic Control as described in Exhibit A, SOW.

( 1) THE ABOVE QUANTITIES ARE ESTIMATES ONLY AND ARE GIVEN AS A BASIS FOR COMP ARIS ON OF BIDS. NO GUARANTEE IS MADE OR IMPUED AS TO THE EXACT QUANTITY lHAT WILL BE NEEDED.

(2) IN CASE OF DISCREPANCY BETWEEN THE UNIT PRICE AND THE TOTAL SET FORTH FOR A UNIT BASIS ITEM, THE UNIT PRICE SHALL PREVAIL.

TOTAL THIS PROPOSAL (Add Line Items 6 and 7)

$ 3 z.-z.oo ~

$ soo~

$ 3'54, SOC>~

(3) PLEASE DO NOT ALTER, MODIFY OR CHANGE THIS BID PROPOSAL SHEET. ANY AL TERA TIONS, MODIFICATIONS, OR CHANGES TO THJS THJS BID SHEET WILL BE GROUNDS TO REJECT THlE BID.

( 4) EACH LINE LITEM MUST BE BID. PLEASE DO NOT LEA VE ANY UNIT PRICE COLUMN BLANK OR THIS BID PROPOSOAL SHEET WILL BE DISQUALIFIED FROM COMPETTION FOR CONTRACT AW ARD.

State of California-Department of General Services, Procurement Division GSPD--05--105 (EST 8/05)

ATTACHMENT 2

BIDDER DECLARATION

1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form):

a. Identify current California certification(s) (MB, SB, SB/NVSA, DVBE): AA p.._, or None_ (lf"None·: go to Item #2)

Invitation for B id IFB Number 04A541 1

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b. Will subcontractors be used for this contract? Yes ✓No_ (If yes, indicate the distinct element of work your firm will perform in this contract e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary.

((; ~ \\ do ull u:-,t, ( 'g, E'.&Cc: \?+ Tn:._{,-\~ c ( 'o ,l\:+~c)( ' C.J&i \./,ec; we C)L,J e oU -+ ~ . . { l i 9 0"\f \JU.Vt:- :±::e, ( 0 -f \\e__ (L)O( ~

c. If you are a California certified DVBE: (1) Are you a broker or agent? Yes _No_ (2) If the contract includes equipment rental, does your company own at least 51 % of the equipment provided in this contract (quantity and value)? Yes ~ o _N/A _

2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary):

Subcontractor Name, Contact Person, Subcontractor Address CA Certification 1/Vork performed or goods provided Corresponding Good 51% Phone Number & Fax Number & Email Address (MB, SB-(5'v'w;r None) for this contract % of bid price Standinq? Rental?

'\(c\l '\.:l 1<...ct_ 0,..__~- l""-,._ S6~i T-c"c.l( V~~ t) · O\lSE }::t; T~c.. ~~rol ~&~ "{ ,e,c_, '1 e..'.> Bo 4 .u,e. ¼ti\ t... t--,\c,,:s wt- cs ~'b~ t'"'2~D7~,;- 1 .. ec,

5"3o- C, 2.5 - l '-(- O'o C...~, °t CoC (:i? 5°31.') - 'i '-'- - O'{S{> .,. o I l V\ eo cJl€t "-~+'1 . c..o II'-\

C..-A <...:. ""'~ q l \ ~ ~ lo

'D \62.. 1,¼_ \. Ot>OD \ 3> b 2{

CERTIFICATION: By signing the bid response, I certify under penalty of perjury that the information provided is true and correct.

Attachment 9

Invitation For Bid IFB Number 04A5411

Page 1 of 1

STATE OF CALIFORNIA- DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS STD. 843 (Rev. 512006)

Instructions: The disabled veteran (DV) owner{s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment [Military and Veterans Code Section 999.2). Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.

SECTION 1

Name of certified DVBE: _________________ _ DVBE Ref. Number: _____ _

Description (materials/supplies/services/equipment proposed):

Solicitation/Contract Number: ___________ _

SECTION 2

SCPRS Ref. Number:--,==-=~==-,-,-::-=-=.,..,..,,,..,,---­(FOR STATE USE ONLY)

APPLIES TO ALL DVBEs. Check only one box in Section 2 and provide original signatures.

D I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2 (b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.

D Pursuant to Military and Veterans Code Section 999.2 (f), I (we) declare that the DVBE is a broker or agent for the principal/s} listed below or on an attached sheet/s}. (Pursuant to Military and Veterans Code 999.2 (e), State funds expended for equipment rented from equipment brokers pursuBf'!t te eef'lt, tiets e .. ei ded uf'!de, ti,is seetiefJ shBIJ w be credited toward the 3-percent DVBE participation goal.)

All DV owners and managers of the DVBE (attach additional page~alll, su1Hcle11t slg11atme blocks lo, each pe1so11 to slg,,): -------

(Printed Name of DV Owner/Manager)

(Printed Name of DV Owner/Manager)

Firm/Principal for whom the DVBE is acting as a broker or agent: (If more than one firm, list on extra sheets.)

Firm/Principal Phone: ______ _ Address:

SECTION 3

(Signature of DV Owner/ Manager) (Date Signed)

(Signature of DV Owner/Manager) (Date Signed)

(Print or Type Name)

APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AtiQ DECLARE THE DVBE IS NOT A BROKER.

D Pursuant to Military and Veterans Code Section 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.

D The undersigned owner(s) own(s) at least 51 % of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsections (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax retum(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections (c) and (g), will result in the DVBE being deemed an equipment broker.

Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):

(Printed Name) (Signature) (Date Signed)

(Address of Owner) (Telephone) (Tax Identification Number of Owner)

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Manager)

PRINT

(Signature of DV Manager) (Date Signed)

Page _of_

Roll 'N Rock Construction Inc. 5527 Truck Village Drive Mount Shasta, CA 96067

License # 971838 A, C61/D49 & C31 TRAFFIC CONTROL DBE# 41928 ~ MB/DVBE # 1750745 ~DIR# 1000013621

SIGNATORY TO LABORERS UNION #324

DATE: 3/7/18 TO: General Contractors

Contract Number: 04A5411 ~ ATTN: Estimators

" ' . Item# Construction Area Signs (Fur:nish,!nstall, an'cl Re~ove) • Stationary CAS Call forCAS prices ) ) • Funding Signs '·~ '·, ; • Motorist/Traffic Handling/Speed Reducti~qe. signs upon request • $800 fee for USA l'l!'ati~ of signs ) · • Traffic control excf ude~ 1 (/ • These prices a~ alid e~em,ir-Rolf n Rock does not provide traffic control

/

Email: rollnrockinc@nctv.com

Phone: (530) 925-1408 Fax: (530) 926-0450

Price: N/A Price: N/A

/,~ '/

/ \._ I ,,,.---.. \ // ~ "~ "'- / \\ .a ,,,_. /< )~,

Item # Traffic Control (T~ 3) < ) I ·, "'-t- •::. ro-. j-e..,. ~ \. 1--z,o-o - ,,-- ...._ "- ,. , ~ \\ • 8Hr. shift with 2 flaggers~ . ' I IA.t';, (?O ~ --$ s7D ~ Price(1 1,400.00

1 \ • 8Hr. shift extra flagge( (-if ne{ded) \ Prlte: $650.00~ • h \v Qc¼i-e.. 2--- 1$, "'l-b, 2 l o ~- "s , / gyertime~te p~r r. J o Pr!ce: 100:po

~ Sum!ays,ani!-~ohdays rate per hr. LJ '2 1 ~~ Price: $1) 5.00

-~ "' J 19; ~ ( ------ \ / ~ No additio al ~harges for night work ©9\.Ji t/) );

7v~&) .,,,--Item'#'-Traffic Cont~ol (T-13) ~ ~ / J )

• Q~te<t:at7y i~clude all cones and advanced warning signs as ne~~d-~ ny addi9onal signage shall be provil d'~Y the prime contractor or rented from Roll 'N Rock. Rate sheet ~ail~ble upon request

V / ~ Item# Pilot ar (T-13) t-' )/ • 8Hr. shift pilot car with driver

• Overtime pilot car with driver, per hr. /( • Sundays and holidays rate per hr. ~

------~ Item # Portable Changeable Message Board

Price: $800.00 Price: $105.00 Price: $120.00

• Message Board: ,.,.._.. '1 co .,.,

o Per Day $300.00 Per-Week-$600.00 Per Month $1,200.00 )( I ~ l rv • Message Board Delivery: ~ :'\ ✓ 10

o Rate: $95.00 hr,7 ~ port if Roi 'N j ock provides Traffic Control ,(( ?, l< ")-. "'I\,':>

Item # Rumble Strips ~ ~ /

o Per Day $300.00 Pe ~ 790.00 Per Month $1,400.00

ACKNOWLEDGEMENT & AGREEMENT: BY APPOINTING OR LISTING ROLL 'N ROCK CONSTRUCTION INC. AS A SUBCONTRACTOR ON THIS PROJECT, THE PRIME CONTRACTOR ACKNOWLEDGES AND AGREES TO ALL APPLICABLE TERMS ANO CONDITIONS DESCRIBED ON PAGE 3 OF THIS PROPOSAL. THESE TERMS & CONDITIONS ARE BINDING AND MUST BE INCLUDED IN EACH EXECUTED SUBCONTRACT AGREEMENT MADE BETWEEN YOUR FIRM AND ROLL 'N ROCK CONSTRUCTION INC.

Page 1 of4

Roll 'N Rock Construction Inc. ;

Item# Lane/Shoulder/Ramp Closure 2 Miles (T-10, T-11 and T-14) . ~' • 8Hr. shift with 1 TC person, cone truck and 1 arrow board Price: $950.00 " • 8Hr. shift with 2 TC persons, cone truck and 1 arrow board Price: $1,450.00 X. <e,-'l' • 8Hr. shift extra TC person (if needed) Price: $650.00

0 • Overtime rate per TC person per hr. (truck included) Price: $105.00X 1,,1' t,.~'b') • Sundays and holidays rate per hr. ~ Price: $115.00 ~ • No additional charges for night WOJk ~ ,-1,_ \J) ,-;r

,_ \ ~ ,er •'b:,, .tf

Item# Additional Closures-Same Cr~'(-i:'J.O,}; lla';;d T~1) C\.0~

• Additional lane closure/opposite dir~t~d'(lnclude~·~rrow board) Price: $150.00 -;( (p I/ I\...., • Additional ramp closure , '..... ~' Price: $150.00 )(' 5 1 • Additional detour (6 signs or less) ~ / Price: $150.00

/ ~ /"" Item# Traffic Control (J.(10, T-ll)a~,,d-T--~4) ,._ ,- '

• Quoted rates indu~e all cones-an~ a'ctvanced warning signs as needed, up to 2 milesf Any adaitional signage shall liepr0vicled· f(y the p/ i~e contractor or rented from Roll 'N Rock. Ra{e sheet av~i~ble l\ upon request "........_ ~ / ,~ "'"' < f'

Item# Attenuato~ck )/ ~ v/ • Att~ator Track: ,,. -- ")// \~Q

/ / ~ )-, ,,. \ , l\'U .(o Per Day $6f0,00 Per Week $1,600.00 Per Month $4,090,00--....._, 1

) u ~ ' ' J o Fuel nof\lnaluded in rental rate ~~ / ( ) v------\ ~ 'l tJ} 0"' 8 hr. shift f ith operator g j- , ~/------P~ice: $950.00 X . , ~ "'......_ Q~rti,~ rate_with operator per hr. ~ < P~i~k: $125.00 x']J( 'o

• Attenu~or--Tr,uck Delivery: , '-......_ "" / 1

o RatEV$100.00 hr. port to port if Roll 'N Rock prg.vicles Traffic Control" /1/ i ~\ Ji

ACKNOWLEDGEMENT & AGREEMENT: BY APPOINTINo/P R LISTl.~ROLL 'N ROCK CONSTRUCTION INC. AS A SUBCONTRACTOR ON THIS PROJECT, THE PRIME CON~ACTOR ACKN~WLEDGES AND AGREES TO ALL APPLICABLE TERMS AND CONDITIONS DESCRIBED ON PAGE 3 OF THl:S-PRO~T-H~\ TERMS & CONDITIONS ARE BINDING AND MUST BE INCLUDED IN EACH EXECUTED SUBCONTRACT AGREEMENT-MA.Q~ETWEEN YOUR FIRM AND ROLL 'N ROCK CONSTRUCTION INC.

Respectfully Submitted by,

Bonnie Heile President/ CEO

Roll'n Rock Construction Inc.

t \, /oOD

-; ·~bO

cco 0

l~ 'l <.::,oD -rz,..ovo

Page 2 of4

Roll 'N Rock Construction Inc.

Extra Items bidding

Item# Description / / Quantity Price Total /

/ ·~

' /,,.~ \, ' / "' '-. /, / ' ,'/ \

"" '"" // // '"' ~,

,,,----, ') / ) « ~~

These prices are only~ lid if R~ Roc)k provides traffic control ,,;;· ''-

'-~( ! /"~/~ )) ACKNOWLEDGEMENT & AGREEMENT--: BY/ APPOINTING OR LISTING ROLL 'N ROCK CONST~ N INC. AS A SUBCONTRACT~ON_THIS PROJECT, TliE/ PRIME CONTRACTOR ACKNOWLEDGES AND AGREES TO ALL APP~ICA~LE TERMS AND fONDlll~S'f>~SCRIBED ON PAGE 3 OF THIS PROPOSAL. THESE TERMS &;:oND~TIONS ARE BINDIN

1G AND

MUST BE ~~(UDED IN EACH '~XECUTED SUBCONTRACT AGREEMENT MADE BETW~EN-Y8UR li)IRM AND ROLL 'N ROCK

CONST,Uct~N INC. ) ) t\!J " ) ,,,--------.\ ~" "" J a ~ ""-/, /\ \

Respectfully Sub'r,,-tt€d b~ , f ~ "-._ /!I) /I '. ~//

~~ h\ }/ /(- \ ~ Bonnie Heile

President/ CEO

Roll'n Rock Construction Inc.

Page 3 of4

STtATE OF CALIFORNIA- DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS STD. 843 (Rev. 5/2006)

Instructions: The disabled veteran (DV) owner(s) and DV manager(s) of the Disabled Veteran Business Enterprise (DVBE) must complete this declaration when a DVBE contractor or subcontractor will provide materials, supplies, services or equipment [Military and Veterans Code Section 999.2]. Violations are misdemeanors and punishable by imprisonment or fine and violators are liable for civil penalties. All signatures are made under penalty of perjury.

SECTION 1

Name of certified DVBE: Roll' N Rock Constructi on, INC.

Description (materials/supplies/services/equipment proposed):

Solicitation/Contract Number: __ 0_4_A ___ 5_4 ___ 11 _ ____ ___ _

SECTION2

DVBE Ref. Number: 1750745 _........, _______ _ Tr affic Cont r ol

SCPRS Ref. Number:. ______________ _

(FOR STATE USE ONLY)

APPLIES TO ALL DVBEs. Check only .Q!!! box in Section 2 and provide original signatures.

0 I (we) declare that the DVBE is not a broker or agent, as defined in Military and Veterans Code Section 999.2 (b), of materials, supplies, services or equipment listed above. Also, complete Section 3 below if renting equipment.

D Pursuant to Military and Veterans Code Section 999.2 (f), I (we) declare that the DVBE is a broker or agent for the principal(s) listed below or on an attached sheet(s). (Pursuant to Military and Veterans Code 999.2 (e), State funds expended for equipment rented from equipment brokers pursuant to contracts awarded under this section shall not be credited toward the 3-percent DVBE participation goal.)

All DV owners and managers of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

Bonni e Heile (Printed Name of DV Owner/Manager)

(Printed Name of DV Owner/Manager)

Firm/Principal for whom the DVBE is acting as a broker or agent: (If more than one firm, list on extra sheets.)

Firm/Principal Phone: ______ _ Address:

SECTION 3

~~ 3/7/18 (Signature of DV Owner/ Manager) (Date Signed)

(Signature of DV Owner/Manager) (Date Signed)

(Print or Type Name)

APPLIES TO ALL DVBEs THAT RENT EQUIPMENT AND DECLARE THE DVBE IS NOT A BROKER.

0 Pursuant to Military and Veterans Code Section 999.2 (c), (d) and (g), I am (we are) the DV(s) with at least 51% ownership of the DVBE, or a DV manager(s) of the DVBE. The DVBE maintains certification requirements in accordance with Military and Veterans Code Section 999 et. seq.

0 The undersigned owner(s) own(s) at least 51 % of the quantity and value of each piece of equipment that will be rented for use in the contract identified above. I (we), the DV owners of the equipment, have submitted to the administering agency my (our) personal federal tax return(s) at time of certification and annually thereafter as defined in Military and Veterans Code 999.2, subsections (c) and (g). Failure by the disabled veteran equipment owner(s) to submit their personal federal tax return(s) to the administering agency as defined in Military and Veterans Code 999.2, subsections (c) and (g), will result in the DVBE being deemed an equipment broker.

Disabled Veteran Owner(s) of the DVBE (attach additional pages with signature blocks for each person to sign):

Bonnie Heile -~~---(Printed Name) (Signature)

3/7/18 (Date Signed)

552 7 Tr uc k Vill age Drive, Mount Shasta , CA 96067 45- 44 66518 (Address of Owner)

530 . 925 . 1408 (Telephone) (Tax Identification Number of Owner)

Disabled Veteran Manager(s) of the DVBE (attach additional pages with sufficient signature blocks for each person to sign):

(Printed Name of DV Manager) (Signature of DV Manager) (Date Signed)

Page _ 1 of _ 1_