ITB-U-10-03 - Water Treatment Plant No. 1 - Backwash Water...

ITB-U-10-03 - Water Treatment Plant No. 1 - Backwash Water Piping Replacement

Required Submittal Packet

1. All addenda (signed and dated)

2. Bid Bond

3. The following thirty-five (35) pages (filled out completely) Only the above mentioned items need to be submitted. Please be sure to include the bid name and number, as well as your company’s name, address and phone number, on the outermost envelope and please mark submittals as “original” and “copy”. Failure to provide all of the required submittals may result in the bid to be considered non-responsive. Confidential Materials: Any materials that qualify as “trade secrets” shall be segregated and clearly labeled in order not to be considered Public Record.

*Originally form 00150-01 Trench Safety Act was included in the Required Submittals Packet but that form will not be needed per the engineer so it has been removed.

SECTION 00100 BID FORM

CITY OF PALM COAST, FLORIDA FOR THE CONSTRUCTION OF

PROJECT: Water Treatment Plant No. 1– BBaacckkwwaasshh PPiippiinngg RReeppllaacceemmeenntt CITY CONTRACT NO.: ITB-U-10-03 Name of Bidder: Mailing Address: Street Address: City/State/Zip: Phone Number: (_______) FAX Number: (________) Contractor License Number: TO: Purchasing and Contacts Management Division of the City of Palm Coast, Florida Pursuant to and in compliance with your notice inviting sealed Bids (Invitation for Bid), Instructions to Bidders, and the other documents relating thereto, the undersigned Bidder, having ensured to its satisfaction that they have familiarized themselves with the terms of the Contract Documents, local conditions affecting the performance of the Work, and the cost of the Work at the place where the Work is to be done, hereby proposes and agrees to perform within the time stipulated in the Contract Documents, including all of its component parts and everything required to be performed, and to provide and furnish any and all of the labor, Material, and tools, expendable Equipment, and all utility and transportation services necessary to perform the Work and complete in a workmanlike manner, all of the Work required in connection with the construction of said Work all in strict conformity with the Plans and Specifications and other Contract Documents, including Addenda Nos. _____________ through_____________, on file at the Purchasing and Contracts Division for the Total Bid (Contract Price) hereinafter set forth. The undersigned Bidder agrees that the Work shall be completed according to the schedule set forth in the Contract Documents. The undersigned Bidder further agrees to pay liquidated damages as described in the Contract Documents.

BID FORM 00100-1 December 2009 ITB-U-10-03

Water Treatment Plant No. 1 Backwash Water Piping Replacement



words in accordance with these Instructions to Bidders in the blank pace(s) provided for that purpose.

idder acknowledges that it has read and fully understands all Sections of the Instructions to idders.

s may sult in a finding that the Bidder is non-responsive and may cause a forfeiture of the Bid Security.

Y directly or via the website (www.ci.palm-coast.fl.us/government/

Bid prices must be stated ins BB The undersigned, as Bidder, declares that the only persons or parties interested in this proposal as principals are those named herein; that this proposal is made without collusion with any person, firm or corporation; and he proposes and agrees, if the proposal is accepted, that they will execute an Agreement with the CITY in the form set forth in the Contract Documents; that it will furnish the Contract Security, Insurance Certificates, Endorsements, and Policies, that it is aware that failure to properly comply with the requirements set out in the "Instructions to Bidders" and elsewhere in the Contract Documentre Attention: Bids shall only be considered from those Bidders who have obtained these Contract Documents from the CITdepartments/purchasing).

ocuments and all addenda, if any, issued prior to e date of this Bid at the Total Bid herein as follows:

TOTAL AMOUNT OF BID (ITEM NOS. 1 – xx) $

Pursuant to and in compliance with your Invitation for Bid, the Instructions to Bidders, and other documents relating thereto, the undersigned hereby agrees to furnish all labor, Materials and Equipment to do the Work in strict accordance with the Contract Dth

(Figures)

(In Words)



UNIT PRICE SCHEDULE (Unit Prices for Adjustment) –

TO BE USE ON LUMP SUM BIDS The following unit prices, if approved by the City shall be used for adjusting the Contract price for changes in the work (additions or deletions) in accordance with the provisions of an approved change order and any other modifications of the Contract. Unit prices shall include all labor, materials, equipment, transportation, and supervision representing an in-place price for each item. Scope or size of each item not otherwise indicated is as described in the construction specifications and drawings. The City reserves the right to approve or reject the below list on a line item basis

ITEM DESCRIPTION UNIT UNIT PRICE

ADDENDA

The following Addenda, if any, were received:

Addendum No.______________________ Date Received_________________



Addendum No.______________________ Date Received_________________ Bidder Acknowledgements:

1. The Bidder acknowledges that the Total Amount of Bid stated above includes the sum of $250.00 or 1% of the Bid whichever is greater, specific consideration for indemnification.

2. The Bidder acknowledges that the Total Amount of Bid stated above includes compensation for all Work, labor, permits, bonds, equipment, materials, and any and all incidental costs necessary for the proper execution of the required services.



Attention: Bids shall only be considered from those Bidders who have obtained these Contract Documents from the CITY directly or via the website (www.ci.palm-coast.fl.us/government/departments/purchasing). The Bidder acknowledges the receipt, execution, and return of the following forms:

Section 00100 - Bid Forms, including alternates and addendum, if any. Section 00160 - Bidder Information Forms (Including W-9 and Public Entity Crimes Form) Section 00300 - Non-Collusion Affidavit of Bidder Form Section 00310 - Certification of Nonsegregated Facilities Form Section 00330 - Drug-Free Workplace Form Section 00335 – Conflict of Interest Statement Section 00336 – Compliance with Public Records Law Section 00337 - Americans with Disabilities Act Affidavit IN WITNESS WHEREOF, BIDDER has hereunto executed this BID FORM this _________ day of ______________, 20_____. ______________________________ _______________________________________ (Name of BIDDER) (Signature of person signing this BID FORM) _______________________________________ (Printed name of person signing this BID FORM) _______________________________________ (Title of person signing this BID FORM) ACCOMPANYING THIS BID IS_________________________________________________________

(insert the word(s) "cashier's check," bidder's bond," certified check," or other security as provided by

law, as the case may be) in an amount equal to at least five percent (5%) of the Total Bid, payable to the

CITY OF PALM COAST, FLORIDA

The undersigned deposits above-named security as a Bid guarantee and agrees that it shall be

forfeited to the CITY as liquidated damages (and not as a penalty in recognition of the complexity and

lack of precision in calculating damages) in case this Bid is accepted by the CITY and the undersigned

fails to execute an Agreement with the CITY as specified in the Contract Documents accompanied by the

http://www.ci.palm-coast.fl.us/government/departments/purchasing

http://www.ci.palm-coast.fl.us/government/departments/purchasing



required Payment and faithful Performance Bonds with Sureties satisfactory to the CITY, and

accompanied by the required certificates of insurance coverage, and endorsements.

Should the CITY be required to engage the services of an attorney in connection with the

enforcement of this Bid, Bidder promises to pay City’s reasonable attorney's fees and costs (including

attorney's fees and costs on appeals) incurred with or without suit.

We, the Undersigned, hereby declare that no person, persons, firm, or corporation, other than the

undersigned are interested in this Proposal as principals and that this Proposal is made without collusion

with any person, firm, or corporation. CORPORATION/COMPANY Company Name: (Seal) By: (Name typed or printed) By: (Name typed or printed) Address: Telephone No.: (___) FAX No.: (___) Florida State Registration Number: Federal I.D. Tax Number: INDIVIDUAL Name: (Signature) (Name typed or printed) (Title) Address: Telephone No.: (___) FAX No.: (___) County/City Registration Number: Social Security Number: Federal I.D. Tax Number: ______



Attachments: “A” Material and Equipment List “B” List of Proposed Subcontractors/Shop Fabricators “C” Certificate of Corporation “D” Questionnaire “E” Direct Purchase of Materials All attachments must be completed and attached to Bidders’ Bid Proposal.



ATTACHMENT A

MATERIAL AND EQUIPMENT LIST Listed below are items of material and/or equipment proposed for use in the project. The Bidder is required to fill in the manufacturer for each listed piece of material and/or equipment. FAILURE TO COMPLETELY FILL IN THE LIST SHALL CONSTITUTE A NON-RESPONSIVE BID AND SHALL BE A CAUSE FOR REJECTION. BIDDER acknowledges that the bid is based on all of the specified products, unless specifically approved in writing by addendum prior to the bid date. SECTION MATERIAL AND/OR EQUIPMENT MANUFACTURER _15060____ Piping and Fittings___________________ __________________________ _15100____ Valves and Appurtenances_____________ __________________________ _ _Flow Meter ________ __________________________ By: _____________________________________________________________ Bidder _________________________________________________________________ Authorized Signature _________________________________________________________________ Date



ATTACHMENT B

LIST OF PROPOSED SUBCONTRACTORS/SHOP FABRICATORS


ITB-U-09-xx

THE CITY OF PALM COAST The Bidder expressly agrees that: 1. If awarded a Contract as a result of this Proposal, the major subcontractor and/or shop fabricator used in the prosecution of the work shall be those listed below. Only one (1) subcontractor and/or shop fabricator shall be listed in each category. 2. The following list includes all subcontractors and/or shop fabricators who will perform work. 3. The Bidder represents that the subcontractors and/or shop fabricators listed below are financially responsible and are qualified to do the work required. (Attach additional sheets if necessary.)

FAILURE TO COMPLETELY FILL IN THE LIST SHALL CONSITITUTE A NON-RESPONSIVE BID AND SHALL BE A CAUSE FOR REJECTION

PREVIOUS WORK

EXPERIENCE TOGETHER?

CATEGORY NAME/ADDRESS YES NO



ATTACHMENT C

CERTIFICATE OF CORPORATION

STATE OF FLORIDA COUNTY OF I HEREBY CERTIFY that a meeting of the Board of Directors of , a corporation under the laws of the State of , was held on , 20 . The following resolution was duly passed and adopted:

“RESOLVED, that

as President of the corporation is hereby authorized to execute the

Contract dated , 20 , between The City of Palm Coast, a municipal

corporation and this corporation, and that execution thereof, attested by the Secretary of the

corporation and with corporate seal affixed, shall be the official act and deed of this corporation.”

I further certify that said resolution is now in full force and effect.

IN WITNESS THEREOF, I have hereunto set my hand and affixed the official seal of the corporation

This day of , 20 .

Corporate Secretary



ATTACHMENT D

QUESTIONNAIRE

DATE: ____________________________________________________ NAME OF BIDDER: ________________________________________ BUSINESS ADDRESS: ______________________________________ ___________________________________________________________ PHONE NUMBER: __________________________________________ CONTRACTOR'S FL. LICENSE #: _____________________________ EXPIRATION DATE: ________________________________________ The undersigned warrants the truth and accuracy of all statements and answers herein contained. Include additional sheets if necessary. 1. How many years has your organization been in business as a (General Contractor or ____________________________)?________________________________________________ 2. How many years has your organization been in business as a Subcontractor?_________________ 3. Describe in detail and give the date and owner, including phone numbers and contact person(s),

of the last ten (10) projects that you have completed similar in type, size, and nature as the project proposed? Please state if you were the main general contractor or sub-contractor (use additional sheets if needed).

4. Have you ever failed, or been alleged to have failed, to complete work awarded to you? If so,

where and why?



5. Have you ever failed, or been alleged to have failed, to complete work within the Contract Time? If so, where and why?

6.. Have you ever been assessed liquidated damages, or had liquidated damages assessed against

you? If so, where and why? 7. Have you ever had your bonding restricted or limited? 8. Have you ever had a bond or letter of credit called by the owner of a project? If so, when? 9. Name three (3) individuals or corporations, not mentioned in 3 above, for which you have

performed work and to which you refer: 10. Have you personally inspected the site of the proposed Work? Describe, in full, any anticipated

problems with the site and your proposed solutions? 11. What equipment do you own that is available for the Work? 12. What equipment will you purchase for the Work?



13. What equipment will you rent for the Work? 14. Complete the required disclosure form. 15. Attach a copy of the most current balance sheet (assets and liabilities) for the BIDDER. 16. State the true and exact, correct, and complete name under which you do business. BIDDER is: By (Signature) Seal (Title) 17. Attach the corporate information sheet from the Florida Department of State, Division of

Corporation’s, web site. Sworn and subscribed to before me this day of ,, 20 ,, in the State of ,, County of .. Notary Public My Commission Expires:



REQUIRED DISCLOSURE The following disclosure is of all material facts pertaining to any felony conviction or any pending felony charges in the last three (3) years in this State or any other state or the United States against (1) the Bidder, (2) any business entity related to or affiliated with the Bidder or (3) any present or former owner of the Bidder or of any such related or affiliated entity. This disclosure shall not apply to any person or entity which is only a stockholder, which person or entity owns twenty percent (20%) or less of the outstanding shares of the Bidder whose stock is publicly owned and traded:



ATTACHMENT E

DIRECT PURCHASE OF MATERIALS DATE: ____________________________________________________ NAME OF BIDDER: ________________________________________ BUSINESS ADDRESS: ______________________________________ ___________________________________________________________ PHONE NUMBER: __________________________________________ CONTRACTOR'S FL. LICENSE #: _____________________________ EXPIRATION DATE: ________________________________________ PART 1 GENERAL 1.01 It is the intent of the City, being a tax exempt governmental entity, to save the sales tax on the major quantities of materials supplied for this project. PART 2 PRODUCTS

Table of Potential Items to be Direct Purchased by the City:

The table in Part 2 must be filled out in its entirety upon executed Notice of Award.

Column A

Column B

Column C

Column D

Materials For Potential

Direct Purchase

*Material Invoice Amount

Sales Tax on Material Amount

Contract Reduction Amount (B + C)

* Invoices for the material shall be provided to the City.



PART 3 – EXECUTION 3.01 For bidding purposes and contract award, the Contractor shall bid the job as they normally would with sales tax included as part of their Bid. The Contractor shall act as the City’s purchasing agent for the purchase of various items enumerated above and thus, the City shall be the buyer in such transactions and, being a tax exempt governmental entity, the purchase transaction shall be tax exempt. However, should the Florida Department of Revenue ultimately conclude that sales tax should have been paid; the City agrees to pay the sales taxes and ensure that the Contractor is not required to pay such taxes. The Contractor shall not be obligated to defend the City against the Florida Department of Revenue for any actions by the Department claiming that sales taxes are due to the State under this Contract. The Contractor shall be responsible to place the order for the material. The Work Order shall be issued by the City with the Contractor’s terms and conditions. Goods shall not be subject to trade discounts. Agreement for the City to purchase shall be formalized prior to purchase of goods. Shop drawings shall be sent to the Contractor from the Material Supplier for review, checking and coordination. After checking, the Contractor shall be responsible to forward the shop drawings to the ENGINEER for review. After review with the City, the ENGINEER shall return the shop drawings to Contractor to be returned to the Material Supplier. The Contractor shall be responsible to schedule the delivery time for the material. The Contractor shall be responsible to unload and to store the material until it is installed. The Contractor shall be responsible to provide and maintain Builders Risk Insurance on the material until the project is completed and accepted by the City. Invoices for the Material shall be submitted to the City, c/o Contractor. The Contractor shall forward the invoices to the ENGINEER. Once the ENGINEER has reviewed the invoice and the Contractor has confirmed delivery, this information shall then be forwarded to the City for payment. Payment shall be forwarded in accordance with Work Order Terms. A change order shall be negotiated that reduces the Contract Price by the amount of the material cost plus state sales tax credit (6%) and the local sales tax credit (one percent (1%) up to the first five thousand dollars ($5,000) per invoice. The Contractor shall include in his bid the handling costs, markup and profit that are associated with the installation/handling of the material. The Contractor agrees that the materials listed in Part 2 shall be added to or deleted from at the City’s choosing. The Contractor shall include all costs of administering this direct purchase of material with their bid.



The Contractor shall complete all activities and assume all liabilities that are normally involved in material purchase and installation. The only intent of this Section is for the City to purchase the material directly in order to save the sales tax monies.

END OF SECTION

BIDDER INFORMATION Bidder shall complete the following information and include with their bid submittal.

Bidder Information _______________________________

CONTRACTING

OFFICER

TITLE

OFFICER'S FULL LEGAL NAME

President

Vice-President

Secretary

Treasurer

Resident Superintendent

Indicate with an asterisk (*) in the first column, which officer will sign the resulting contract. If other than the President, include a copy of the corporate resolution which gives express authority for execution of the specific proposal and contract documents. Each Bidder must assure that the officer information provided is in accordance with the Bidder's corporate registration supplied to the Secretary of State.

BIDDER INFORMATION – 00160-1 December 2009 ITB-U-10-03




EXPERIENCE OF BIDDER

NAME OF BIDDER _____________________________________________________ The Bidder shall provide the following information regarding experience within the past three years in this particular scope of work. Bidder must demonstrate ability to construct projects of similar complexity, nature and size as this project. Under Client's Name and address, please include Contact's name, Telephone Number and Fax Number. DATE OF CONTRACT

CLIENT’S NAME & ADDRESS: CONTRACT AMOUNT

PH FX $

Project & Location: DATE OF CONTRACT


PH FX $



PH FX $



PH FX $

Project & Location: Do you have any similar work in progress at this time?____Yes ____No Length of time in business: _______________Years (Minimum three (3) years required) Bank or Financial references: (Include Contact Name and telephone number) ____________________________________________________________________ ____________________________________________________________________



SWORN STATEMENT UNDER SECTION 287.133(3) (a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES

THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted to The City of Palm Coast

((Name of public entity)) ______________________________________________________bbyy ((IInnddiivviidduuaall’’ss nnaammee aanndd ttiittllee)) FFoorr ((Name of entity submitting sworn statement)) whose business address is and (if applicable) its Federal Employer Identification Number (FEIN) is .. (If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement:)

1. I understand that a “public entity crime” as defined in Section 287.133(1)(g), Florida Statutes, means a violation of any State or Federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

2. I understand that “convicted” or “conviction” as defined in Paragraph 287.133(1) (b), Florida Statutes,

means a finding of guilt or a conviction of a public entity crimes, with or without an adjudication of guilt, in any Federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere.

3. I understand that an “affiliate” as defined in Section 287.133(1)(a), Florida Statutes, means:

A predecessor or successor of a person convicted of a public entity crime: or an entity under the control of any natural person who is active in the management of the entity and how has been convicted of a public entity crime. The term “affiliate” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one (1) person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm’s length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding thirty-six (36) months shall be considered an affiliate.

4. I understand that a “person” as defined in Section 287.133(1) (e), Florida Statutes, means any natural

person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term “person” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.

5. Based on information and belief, the statement which I have marked below is true in relation to the entity

submitting this sworn statement. (You must indicate which statement applies.)



__________________Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agent who is active in management of the entity, nor the affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. __________________The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members or agent who are active in management of the entity, or an affiliate of the entity, has been charged with and convicted of a public entity crime subsequent to July 1, 1989. __________________The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members or agents who are active in management of the entity, or an affiliate of the entity, has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before an Administrative Law Jury of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Administrative Law Jury determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (You must attach a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CITY OF PALM COAST IS FOR THE CITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31, OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE CITY PRIOR TO ENTERING IN TO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUES, FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. SIGNATURE DATE State of County of

PERSONALLY APPEARED BEFORE ME, the undersigned authority, __________________________________________________________________________________________who, after first being sworn by me, (Name of individual signing) affixed his/her signature in the space provided above on the day of 20 ..

NOTARY PUBLIC

My commission expires:

EENNDD OOFF SSEECCTTIIOONN

INSTRUCTIONS TO PRINTERSFORM W-9, PAGE 1 of 4MARGINS: TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD to HEADPAPER: WHITE WRITING, SUB. 20. INK: BLACKFLAT SIZE: 216mm (81⁄ 2 ") 3 279mm (11")PERFORATE: (NONE)

Give form to therequester. Do notsend to the IRS.

Form W-9 Request for TaxpayerIdentification Number and Certification

(Rev. October 2007) Department of the TreasuryInternal Revenue Service Name (as shown on your income tax return)

List account number(s) here (optional)

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Pri

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pe

See

Sp

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2.

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoidbackup withholding. For individuals, this is your social security number (SSN). However, for a residentalien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it isyour employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Social security number

or

Requester’s name and address (optional)

Employer identification number Note. If the account is in more than one name, see the chart on page 4 for guidelines on whosenumber to enter. Certification

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the InternalRevenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS hasnotified me that I am no longer subject to backup withholding, and

2.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you mustprovide your correct TIN. See the instructions on page 4. SignHere

Signature ofU.S. person ©

Date ©

General Instructions

Form W-9 (Rev. 10-2007)

Part I

Part II

Business name, if different from above

Cat. No. 10231X

Check appropriate box:

Under penalties of perjury, I certify that:

13 I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

TLS, have youtransmitted all R text files for this cycle update?

Date

Action

Revised proofsrequested

Date

Signature

O.K. to print

Use Form W-9 only if you are a U.S. person (including aresident alien), to provide your correct TIN to the personrequesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you arewaiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S.exempt payee. If applicable, you are also certifying that as aU.S. person, your allocable share of any partnership income froma U.S. trade or business is not subject to the withholding tax onforeign partners’ share of effectively connected income.

3. I am a U.S. citizen or other U.S. person (defined below).

A person who is required to file an information return with theIRS must obtain your correct taxpayer identification number (TIN)to report, for example, income paid to you, real estatetransactions, mortgage interest you paid, acquisition orabandonment of secured property, cancellation of debt, orcontributions you made to an IRA.

Individual/Sole proprietor

Corporation

Partnership

Other (see instructions) ©

Note. If a requester gives you a form other than Form W-9 torequest your TIN, you must use the requester’s form if it issubstantially similar to this Form W-9.

● An individual who is a U.S. citizen or U.S. resident alien, ● A partnership, corporation, company, or association created or

organized in the United States or under the laws of the UnitedStates, ● An estate (other than a foreign estate), or

Definition of a U.S. person. For federal tax purposes, you areconsidered a U.S. person if you are:

Special rules for partnerships. Partnerships that conduct atrade or business in the United States are generally required topay a withholding tax on any foreign partners’ share of incomefrom such business. Further, in certain cases where a Form W-9has not been received, a partnership is required to presume thata partner is a foreign person, and pay the withholding tax.Therefore, if you are a U.S. person that is a partner in apartnership conducting a trade or business in the United States,provide Form W-9 to the partnership to establish your U.S.status and avoid withholding on your share of partnershipincome. The person who gives Form W-9 to the partnership forpurposes of establishing its U.S. status and avoiding withholdingon its allocable share of net income from the partnershipconducting a trade or business in the United States is in thefollowing cases: ● The U.S. owner of a disregarded entity and not the entity,

Section references are to the Internal Revenue Code unlessotherwise noted.

● A domestic trust (as defined in Regulations section301.7701-7).

Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) ©

Exempt payee

Purpose of Form

INSTRUCTIONS TO PRINTERSFORM W-9, PAGE 2 of 4MARGINS: TOP 13 mm (1⁄ 2"), CENTER SIDES. PRINTS: HEAD to HEADPAPER: WHITE WRITING, SUB. 20. INK: BLACKFLAT SIZE: 216 mm (81⁄ 2") 3 279 mm (11")PERFORATE: (NONE)

Form W-9 (Rev. 10-2007) Page 2

Sole proprietor. Enter your individual name as shown on yourincome tax return on the “Name” line. You may enter yourbusiness, trade, or “doing business as (DBA)” name on the“Business name” line.

13 I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING


Other entities. Enter your business name as shown on requiredfederal tax documents on the “Name” line. This name shouldmatch the name shown on the charter or other legal documentcreating the entity. You may enter any business, trade, or DBAname on the “Business name” line.

If the account is in joint names, list first, and then circle, thename of the person or entity whose number you entered in Part Iof the form.

Specific Instructions Name

Exempt Payee

5. You do not certify to the requester that you are not subjectto backup withholding under 4 above (for reportable interest anddividend accounts opened after 1983 only). Certain payees and payments are exempt from backupwithholding. See the instructions below and the separateInstructions for the Requester of Form W-9.

Civil penalty for false information with respect towithholding. If you make a false statement with no reasonablebasis that results in no backup withholding, you are subject to a$500 penalty. Criminal penalty for falsifying information. Willfully falsifyingcertifications or affirmations may subject you to criminalpenalties including fines and/or imprisonment.

Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to arequester, you are subject to a penalty of $50 for each suchfailure unless your failure is due to reasonable cause and not towillful neglect.

Misuse of TINs. If the requester discloses or uses TINs inviolation of federal law, the requester may be subject to civil andcriminal penalties.

If you are an individual, you must generally enter the nameshown on your income tax return. However, if you have changedyour last name, for instance, due to marriage without informingthe Social Security Administration of the name change, enteryour first name, the last name shown on your social securitycard, and your new last name.

If you are exempt from backup withholding, enter your name asdescribed above and check the appropriate box for your status,then check the “Exempt payee” box in the line following thebusiness name, sign and date the form.

4. The IRS tells you that you are subject to backupwithholding because you did not report all your interest anddividends on your tax return (for reportable interest anddividends only), or

3. The IRS tells the requester that you furnished an incorrectTIN,

2. You do not certify your TIN when required (see the Part IIinstructions on page 3 for details),

You will not be subject to backup withholding on paymentsyou receive if you give the requester your correct TIN, make theproper certifications, and report all your taxable interest anddividends on your tax return.

1. You do not furnish your TIN to the requester,

What is backup withholding? Persons making certain paymentsto you must under certain conditions withhold and pay to theIRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding includeinterest, tax-exempt interest, dividends, broker and barterexchange transactions, rents, royalties, nonemployee pay, andcertain payments from fishing boat operators. Real estatetransactions are not subject to backup withholding.

Payments you receive will be subject to backupwithholding if:

If you are a nonresident alien or a foreign entity not subject tobackup withholding, give the requester the appropriatecompleted Form W-8.

Example. Article 20 of the U.S.-China income tax treaty allowsan exemption from tax for scholarship income received by aChinese student temporarily present in the United States. UnderU.S. law, this student will become a resident alien for taxpurposes if his or her stay in the United States exceeds 5calendar years. However, paragraph 2 of the first Protocol to theU.S.-China treaty (dated April 30, 1984) allows the provisions ofArticle 20 to continue to apply even after the Chinese studentbecomes a resident alien of the United States. A Chinesestudent who qualifies for this exception (under paragraph 2 ofthe first protocol) and is relying on this exception to claim anexemption from tax on his or her scholarship or fellowshipincome would attach to Form W-9 a statement that includes theinformation described above to support that exemption.

Note. You are requested to check the appropriate box for yourstatus (individual/sole proprietor, corporation, etc.).

4. The type and amount of income that qualifies for theexemption from tax. 5. Sufficient facts to justify the exemption from tax under theterms of the treaty article.

Nonresident alien who becomes a resident alien. Generally,only a nonresident alien individual may use the terms of a taxtreaty to reduce or eliminate U.S. tax on certain types of income.However, most tax treaties contain a provision known as a“saving clause.” Exceptions specified in the saving clause maypermit an exemption from tax to continue for certain types ofincome even after the payee has otherwise become a U.S.resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exceptioncontained in the saving clause of a tax treaty to claim anexemption from U.S. tax on certain types of income, you mustattach a statement to Form W-9 that specifies the following fiveitems: 1. The treaty country. Generally, this must be the same treatyunder which you claimed exemption from tax as a nonresidentalien. 2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty thatcontains the saving clause and its exceptions.

Also see Special rules for partnerships on page 1.

Foreign person. If you are a foreign person, do not use FormW-9. Instead, use the appropriate Form W-8 (see Publication515, Withholding of Tax on Nonresident Aliens and ForeignEntities).

● The U.S. grantor or other owner of a grantor trust and not thetrust, and ● The U.S. trust (other than a grantor trust) and not thebeneficiaries of the trust.

Limited liability company (LLC). Check the “Limited liabilitycompany” box only and enter the appropriate code for the taxclassification (“D” for disregarded entity, “C” for corporation, “P” for partnership) in the space provided. For a single-member LLC (including a foreign LLC with adomestic owner) that is disregarded as an entity separate fromits owner under Regulations section 301.7701-3, enter theowner’s name on the “Name” line. Enter the LLC’s name on the“Business name” line. For an LLC classified as a partnership or a corporation, enterthe LLC’s name on the “Name” line and any business, trade, orDBA name on the “Business name” line.


I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING



13

Part I. Taxpayer IdentificationNumber (TIN) Enter your TIN in the appropriate box. If you are a residentalien and you do not have and are not eligible to get an SSN,your TIN is your IRS individual taxpayer identification number(ITIN). Enter it in the social security number box. If you do nothave an ITIN, see How to get a TIN below.

How to get a TIN. If you do not have a TIN, apply for oneimmediately. To apply for an SSN, get Form SS-5, Applicationfor a Social Security Card, from your local Social SecurityAdministration office or get this form online at www.ssa.gov. Youmay also get this form by calling 1-800-772-1213. Use FormW-7, Application for IRS Individual Taxpayer IdentificationNumber, to apply for an ITIN, or Form SS-4, Application forEmployer Identification Number, to apply for an EIN. You canapply for an EIN online by accessing the IRS website atwww.irs.gov/businesses and clicking on Employer IdentificationNumber (EIN) under Starting a Business. You can get Forms W-7and SS-4 from the IRS by visiting www.irs.gov or by calling1-800-TAX-FORM (1-800-829-3676). If you are asked to complete Form W-9 but do not have a TIN,write “Applied For” in the space for the TIN, sign and date theform, and give it to the requester. For interest and dividendpayments, and certain payments made with respect to readilytradable instruments, generally you will have 60 days to get aTIN and give it to the requester before you are subject to backupwithholding on payments. The 60-day rule does not apply toother types of payments. You will be subject to backupwithholding on all such payments until you provide your TIN tothe requester.

If you are a sole proprietor and you have an EIN, you mayenter either your SSN or EIN. However, the IRS prefers that youuse your SSN. If you are a single-member LLC that is disregarded as anentity separate from its owner (see Limited liability company(LLC) on page 2), enter the owner’s SSN (or EIN, if the ownerhas one). Do not enter the disregarded entity’s EIN. If the LLC isclassified as a corporation or partnership, enter the entity’s EIN. Note. See the chart on page 4 for further clarification of nameand TIN combinations.

Note. Entering “Applied For” means that you have alreadyapplied for a TIN or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign ownermust use the appropriate Form W-8.

9. A futures commission merchant registered with theCommodity Futures Trading Commission, 10. A real estate investment trust,

11. An entity registered at all times during the tax year underthe Investment Company Act of 1940, 12. A common trust fund operated by a bank under section584(a), 13. A financial institution,

14. A middleman known in the investment community as anominee or custodian, or 15. A trust exempt from tax under section 664 or described insection 4947.

THEN the payment is exemptfor . . .

IF the payment is for . . .

All exempt payees except for 9

Interest and dividend payments

Exempt payees 1 through 13.Also, a person registered underthe Investment Advisers Act of1940 who regularly acts as abroker

Broker transactions

Exempt payees 1 through 5

Barter exchange transactionsand patronage dividends

Generally, exempt payees 1 through 7

Payments over $600 requiredto be reported and directsales over $5,000 See Form 1099-MISC, Miscellaneous Income, and its instructions. However, the following payments made to a corporation (including grossproceeds paid to an attorney under section 6045(f), even if the attorney is acorporation) and reportable on Form 1099-MISC are not exempt frombackup withholding: medical and health care payments, attorneys’ fees, andpayments for services paid by a federal executive agency.

The chart below shows types of payments that may beexempt from backup withholding. The chart applies to theexempt payees listed above, 1 through 15.

1 2

7. A foreign central bank of issue, 8. A dealer in securities or commodities required to register in

the United States, the District of Columbia, or a possession ofthe United States,

2

The following payees are exempt from backup withholding: 1. An organization exempt from tax under section 501(a), any

IRA, or a custodial account under section 403(b)(7) if the accountsatisfies the requirements of section 401(f)(2), 2. The United States or any of its agencies orinstrumentalities, 3. A state, the District of Columbia, a possession of the UnitedStates, or any of their political subdivisions or instrumentalities, 4. A foreign government or any of its political subdivisions,agencies, or instrumentalities, or 5. An international organization or any of its agencies orinstrumentalities. Other payees that may be exempt from backup withholdinginclude: 6. A corporation,

Generally, individuals (including sole proprietors) are not exemptfrom backup withholding. Corporations are exempt from backupwithholding for certain payments, such as interest and dividends. Note. If you are exempt from backup withholding, you shouldstill complete this form to avoid possible erroneous backupwithholding.

1

1. Interest, dividend, and barter exchange accountsopened before 1984 and broker accounts considered activeduring 1983. You must give your correct TIN, but you do nothave to sign the certification. 2. Interest, dividend, broker, and barter exchangeaccounts opened after 1983 and broker accounts consideredinactive during 1983. You must sign the certification or backupwithholding will apply. If you are subject to backup withholdingand you are merely providing your correct TIN to the requester,you must cross out item 2 in the certification before signing theform.

Part II. Certification

For a joint account, only the person whose TIN is shown inPart I should sign (when required). Exempt payees, see ExemptPayee on page 2.

To establish to the withholding agent that you are a U.S. person,or resident alien, sign Form W-9. You may be requested to signby the withholding agent even if items 1, 4, and 5 below indicateotherwise.

Signature requirements. Complete the certification as indicatedin 1 through 5 below.



I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING


Give name and EIN of:

For this type of account:

3. Real estate transactions. You must sign the certification.You may cross out item 2 of the certification.

A valid trust, estate, or pension trust

6.

Legal entity 4

4. Other payments. You must give your correct TIN, but youdo not have to sign the certification unless you have beennotified that you have previously given an incorrect TIN. “Otherpayments” include payments made in the course of therequester’s trade or business for rents, royalties, goods (otherthan bills for merchandise), medical and health care services(including payments to corporations), payments to anonemployee for services, payments to certain fishing boat crewmembers and fishermen, and gross proceeds paid to attorneys(including payments to corporations).

The corporation

Corporate or LLC electingcorporate status on Form 8832

7.

The organization

Association, club, religious,charitable, educational, or othertax-exempt organization

8.

5. Mortgage interest paid by you, acquisition orabandonment of secured property, cancellation of debt,qualified tuition program payments (under section 529), IRA,Coverdell ESA, Archer MSA or HSA contributions ordistributions, and pension distributions. You must give yourcorrect TIN, but you do not have to sign the certification.

The partnership

Partnership or multi-member LLC

9.

The broker or nominee

A broker or registered nominee

10.

The public entity

Account with the Department ofAgriculture in the name of a publicentity (such as a state or localgovernment, school district, orprison) that receives agriculturalprogram payments

11.

Privacy Act Notice

List first and circle the name of the person whose number you furnish. If only one personon a joint account has an SSN, that person’s number must be furnished. Circle the minor’s name and furnish the minor’s SSN. You must show your individual name and you may also enter your business or “DBA” name on the second name line. You may use either your SSN or EIN (if you have one),but the IRS encourages you to use your SSN. List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TINof the personal representative or trustee unless the legal entity itself is not designated inthe account title.) Also see Special rules for partnerships on page 1.

Note. If no name is circled when more than one name is listed,the number will be considered to be that of the first name listed.

Disregarded entity not owned by anindividual

The owner

12.

13

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain otherpayments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, orcontributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return.The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federalnontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

1

2 3

4

Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personalinformation such as your name, social security number (SSN), orother identifying information, without your permission, to commitfraud or other crimes. An identity thief may use your SSN to geta job or may file a tax return using your SSN to receive a refund.

What Name and Number To Give the Requester Give name and SSN of:

For this type of account:

The individual

1.

Individual The actual owner of the account or,

if combined funds, the firstindividual on the account

2.

Two or more individuals (jointaccount)

The minor 2

3.

Custodian account of a minor(Uniform Gift to Minors Act) The grantor-trustee

1

4.

a. The usual revocable savingstrust (grantor is also trustee) The actual owner

1

b. So-called trust account that isnot a legal or valid trust understate law The owner

3

5.

Sole proprietorship or disregardedentity owned by an individual

Call the IRS at 1-800-829-1040 if you think your identity hasbeen used inappropriately for tax purposes.

1

To reduce your risk: ● Protect your SSN, ● Ensure your employer is protecting your SSN, and ● Be careful when choosing a tax preparer.

Victims of identity theft who are experiencing economic harmor a system problem, or are seeking help in resolving taxproblems that have not been resolved through normal channels,may be eligible for Taxpayer Advocate Service (TAS) assistance.You can reach TAS by calling the TAS toll-free case intake lineat 1-877-777-4778 or TTY/TDD 1-800-829-4059. Protect yourself from suspicious emails or phishingschemes. Phishing is the creation and use of email andwebsites designed to mimic legitimate business emails andwebsites. The most common act is sending an email to a userfalsely claiming to be an established legitimate enterprise in anattempt to scam the user into surrendering private informationthat will be used for identity theft. The IRS does not initiate contacts with taxpayers via emails.Also, the IRS does not request personal detailed informationthrough email or ask taxpayers for the PIN numbers, passwords,or similar secret access information for their credit card, bank, orother financial accounts. If you receive an unsolicited email claiming to be from the IRS,forward this message to [email protected]. You may also reportmisuse of the IRS name, logo, or other IRS personal property tothe Treasury Inspector General for Tax Administration at1-800-366-4484. You can forward suspicious emails to theFederal Trade Commission at: [email protected] or contact them atwww.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).

Visit the IRS website at www.irs.gov to learn more aboutidentity theft and how to reduce your risk.

CITY OF PALM COAST

VENDOR REGISTRATION FORM Reason for submitting Vendor Registration Form (select one): New Vendor for the City Add to the City’s bidder list to receive solicitation notices Address Change Company Name Change FEIN# Change Brief description of goods or services you are providing:

City Department Contact

Company Address Address City State: Zip Code: Contact Phone # ( ) Fax #: E-mail Internet:

FEID/SSN: Check Appropriate Box: Individual Sole/

Proprietor Corporation Partnership Other

Primary Commodity Code Secondary Commodity Codes

INSTRUCTIONS

Print or type Company name and mailing address to which bids may be sent. List contact person and telephone number(s) and who can give information including price quotes. List mail address for queries and internet, URL, if available. List the Company’s (FEIN) Federal Identification Number (the number the Company reports its taxes under) or the owner’s Social Security Number if the Company is a sole Proprietorship or Partnership. This is required for Internal Revenue Service reports.

COMMODITY CODE Refer to Commodity Code list to determine which commodity code most closely identifies the product or service your company provide and list in Primary Commodity Code block. If there are other products or services that your company provides, list up to five (5) additional codes. The Commodity Code list contains the majority of all commodities or services that the City solicits bids or proposals for on a regular basis. If the product or service you provide is not listed here, the City probably does not solicit bids for it on a regular basis. However, if your commodity or service is not listed, submit a separate list clearly identifying your commodity or services, and the City may include it in the future.

Do not list commodities or services that you cannot provide a responsive bid for if solicited. Failure to respond to Invitations (submission of a bid or proposal or a NO-BID statement) indicates a lack of interest and after three times may lead to removal from the bidders list. It is important that you promptly notify us if there is a change of address. Many commodities and services are only solicited occasionally or at lengthy intervals, three (3) to eight (8) years. Since bids are only solicited when there is a requirement, inclusion in the City of Palm Coast bidders list does not guarantee that the bidder will receive a bid for their products or services. Please also visit our website at www.ci.palm-coast.fl.us and/or call fax a request to 386-986-3724.

Mail this page to 160 Cypress Point Parkway, #B-106, Palm Coast, Florida 32164, or fax to 386-986-3724, or E-mail [email protected]. SUBMIT FORM ONLY ONCE. If you wish to submit additional information, mail under separate cover. Do not fax literature!

STATE OF FLORIDA BUSINESS REGISTRATION All vendors doing business with the City should be registered with the State of Florida. If the company is an out of state company, it should have a foreign registration with the State of Florida to do business in Florida. Companies can register online at www.sunbiz.org. for a nominal fee.

IRS CERTIFICATION Under Penalties of perjury, I certify that:

1. The number shown of this form is my correct taxpayer identification number(or I am waiting for one to be issued to me, and 2. I am not subject to backup withholding because (a) I am exempt from backup withholding (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide you correct TIN.

Sign

Here

Signature of

U.S. Person ►

Date►

COMMODITY CODES

8721 Accounting & Auditing Services 99837 Electrical Supplies 91501 Advertising Agencies 91438 Electrical Contractors 91807 Advertising Specialties & Novelties 91840 Employee Benefit Program Providers 99803 Aircraft Engines & Parts 96130 Employment Agencies 03520 Airlines & Air Carriers, nec 93831 Engineering Services, Licenses, Professional, nec 57005 Aluminum Sign Blanks & Accessories 96631 Envelope Converters 90607 Architectural Services, Licenses, Professional 92535 Environmental Engineering & Studies Services 96207 Art & Graphic Design Services 97535 Equipment Rental Services 91813 Asbestos Removal Contractors – Certified 98814 Erosion Control Materials 75510 Asphalt Paving Products 91244 Excavation Contractors, includes Tractor & Site Work 96209 Auctioneering Services – Florida Registered 95838 Farm & Garden Equipment & Supplies 88011 Audio-Visual Equipment, Supplies & Service 77015 Fasteners: Bolts, Nuts, Rivets, Washers, etc. 95714 Automobiles & Light Trucks 98815 Fencing Suppliers, & Installers 07006 Auto, Truck, & Motorcycle Rental & Leasing 99840 Fertilizers & Other Agricultural Chemicals 92917 Automotive Shop Equipment 91849 Financial Consultants 97515 Automotive Shop Equipment 94648 Financial Services, Third Party Lease/Purchase 94625 Banks & Depository Institutions 93633 Fire Trucks & Apparatus 99817 Boats, Marine & Diving Equipment & Supplies 93632 Fire Protection Equipment & Supplies 97521 Boats, Used & Salvage 36020 Floor Coverings, all types 71510 Books, Periodicals, & Newspapers 99844 Food & Grocery Products 21015 Brick & Structural Clay Products 96136 Food Service Equipment & Supplies 90922 Building Construction > $200,000 – Bonding Required 91852 Food Service Providers 90923 Building Construction < $200,000 – Bonding Materials 57838 Forestry Services & Supplies, includes Land Mgmt. 90900 Building Construction Services 97108 Building Materials: Brick, Stone, & Related Materials 40509 Fuel Supplier: Gasoline, Diesel, Aviation 91819 Building Materials: Lumber, Plywood, etc. 55736 Fueling Systems, Pumps, Tanks, Equipment & Service 15513 Building Maintenance Services, nec 99846 Furniture: Office 91821 Business Consulting 28539 Generators & Motors (not automotive) 91427 Carpentry Services 91447 Glass & Glazing Services 91009 Carpet & Upholstery Cleaning Services 68052 guns, Ammunition & Related Supplies 481302 Cellular Service Providers, not equipment 99850 Hardware, all types 33533 Chemicals, nec 92645 hazardous Wastes Services 50525 Chlorine, & Related Chemicals 99852 Heating, Ventilation, & Air Conditioning Contractor 99826 Clothing and Apparel, nec 99852 Heating & Air Conditioning Contractor 80540 Coastal Engineering Services 90646 Highway & Street Construction 93442 Commercial Laundry Equipment & Supplies 91551 Information Systems Consultants (no equipment sales) 05264 Commercial Photography Services 95861 Insurance Carriers, Brokers, Agents & Services, all types 70070 Commercial Printing, all types 96248 Interior Design Services 96207 Commercial Art & Graphic Design 47520 Janitorial Chemicals & Supplies 20827 Communications Services, nec 91039 Janitorial Services 91522 Communications Consultants (Radio, Telephone, etc.) 93846 Laboratory Apparatus & Furniture 55919 Communications Equipment & Accessories (not telephone) 98852 Landscape Services, includes Mowing 74017 Compressors, Equipment & Services, (except HVAC) 90656 Landscape Architects 95823 Computer Facilities Management 93442 Laundry Services & Dry Cleaning 91828 Computer Maintenance & Repair, Mainframe 99859 Laundry Equipment & Suppliers, all types 99829 Computer Maintenance & Repair, Micro 96149 Legal Counsel 91830 Computers, Peripherals, & Software, Mainframe 99860 Library Equipment & Supplies 91829 Computers, Peripherals, & Software, Micro 42056 Library Furniture 91430 Concrete Masonry Work, including Sidewalks 42048 Library Shelving 91455 Concrete, Portlands & Masonry 3274 Lime 92930 Concrete, Ready-mix, Block & Brick 91048 Locksmiths & related Products & Services 75030 Concrete Precast Products 95856 Managed Health Care Providers 65834 Concrete Pipe 91875 Management Consulting Services, nec 97524 Construction Equipment 5052 Marine & Underwear Construction 95220 Correctional Institution Equipment & Supplies 42068 Mattresses, Pillows, & Bed Linens 96224 Courier Services, all types 45059 Measuring & Controlling Devices, nec 96124 Court Reporting Services 92567 Mechanical Engineering Services, nec 6371 Deferred Compensation Providers 92939 Medical & Emergency Equipment & Supplies 94828 Dentist Offices 99857 Medical Laboratories 99052 Detective & Investigative Services 95262 Mental Health Service Providers 91558 Direct Mail Services 90921 Metal Building, all types

5714 Draperies, Blinds, Window Coverings, & Upholstery 3441 Metal-Fabricated, all types 5912 Drug Stores & Pharmacies 3399 Metals-Primary Suppliers (iron, steel, alum., etc) 9611 Economic Consultant 92966 Refuse Collection Services, includes recycling collection 96155 Mined or Quarried Materials, all types 14560 Roofing Contractors 99999 Mold Remediation & Drying 77072 Roofing, Siding & Insulation Materials 327208 Monuments & Grave Markers 75077 Sand, Gravel, Rock related products 94664 Mortgage bankers 99889 School Equipment & Supplies 07012 Motorcycles & Parts & Supplies 72554 Security Systems & Services 5112 Office Supplies (not equipment or furniture) 57054 Sheet Metal Work, all types 93959 Office Equipment (not computers or furniture) 90086 Shoes, all types 99874 Oil, Grease & Related Petroleum Products 80150 Signs, all types 64043 Packaging Materials, nec 79050 Sod, Hay, Seeds, Shrubs & Trees, etc. 91461 Painting Contractors (not auto) 99891 Sporting, Athletic, Playground & Recreation Goods 96755 Paints, Varnishes, & Supplies (all types) 65062 Sports Lighting Equipment & Fixtures 70069 Paper Mills & Distributors 99080 Surveying Services 4119 Paratransit Services 91576 Telephone Service Providers, Local & Long Distance 94050 Passenger Transportation Services, all types 72555 Telephone Equipment & Accessories, includes cellular 91885 Personnel & Human Resource Consultants 90783 Testing Services, Engineering (not medical) 91059 Pest Control Services 99882 Tires & Tubes, Sales & Service 99876 Photo Equipment, Film & Supplies 99893 Tires, Sale of Surplus 65804 Pipe: Metal, all types 95387 Title Abstract Services 65858 Pipe: Polyethylene & PVC 95954 Towing Services, Car & Truck 92672 Planning & Zoning Consultants (land use, impact fees, 55089 Traffic Signals, Supplies & Services 98154 Plumbing Supplies 92593 Traffic Engineering Services 91468 Plumbing Contractors 12090 Trailers, all types 57895 Potable Water Services 95290 Training & Development Consultants 99881 Printing Trades Equipment & Supplies 99820 Transit Vehicles: Bus, Coach, Paratransit 8743 Public Relations Services 96178 Travel Agencies 91573 Public Safety Equipment & Supplies 96239 Trucking & Hauling Services (materials, not people) 72056 Pumps & Pumping Equipment 07048 Trucks: Bucket 95883 Real Estate Agencies 07048 Trucks: Catch Basin & Vacuum 91889 Real Estate Appraiser Services 07051 Trucks: Medium & Heavy Duty 57096 Recycled Metal Products 20085 Uniforms, all types 0120 Recycled Paper Products 98587 Voting Machines, Equipment & Maintenance 64066 Recycled Plastic Products 98184 Water, Sewer & Utility Equipment & Supplies 92677 Recycled Products, nec 96896 Water, Sewer, & Utility Construction & Supplies 92677 Recycling Centers & Processors 54596 Water Well Drilling & Supplies 57864 Recycling Equipment & Supplies 96897 Wrecking & Demolition Work 74059 Refrigeration Equipment & Supplies

NON-COLLUSION AFFIDAVIT OF BIDDER State of ) )ss County of ) _______________________________________________, being first duly sworn, deposes and says that: (1) He/She is ___________________________, of _______________________, the Bidder that has submitted the attached Bid; (2) He/She is fully informed respecting the preparation and contents of the attached Bid and of all pertinent circumstances respecting such Bid; (3) Such Bid is genuine and is not a collusive or sham Bid; (4) Neither the said Bidder nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, has in any way colluded, conspired, connived or agreed, directly or indirectly, with any other Bidder, firm or person to submit a collusive or sham Bid in connection with the Agreement for which the attached Bid has been submitted or to refrain from bidding in connection with such Agreement, or has in any manner, directly or indirectly, sought by agreement or collusion or communication or conference with any other Bidder, firm or person, to fix the price or prices in the attached Bid or of any other Bidder, or to fix any overhead, profit or cost element of the Bid price or the Bid price of any other Bidder, or to secure through collusion, conspiracy, connivance or unlawful agreement any advantage against the City of Palm Coast City Council, Flagler County, Florida, or any person interested in the proposed Agreement; and (5) The prices quoted in the attached Bid are fair and proper and are not tainted by any collusion, conspiracy, connivance or unlawful agreement on the part of the Bidder or any of its agents, representatives, owners, employees or parties in interest, including this affiant. Signed:_______________________________________ Printed Name:________________________________________ Title:_________________________________________

NON-COLLUSION AFFIDAVIT OF BIDDER 00300-1 December 2009 ITB-U-10-03


NON-COLLUSION AFFIDAVIT OF BIDDER 00300-2 December 2009 ITB-U-10-03


STATE OF ) ) ss COUNTY OF ) The foregoing instrument was acknowledged before me this ____________day of ____________________, 20_____, by ____________________________________ who is personally known to me or who has produced ____________________________________________ identification. _____________________________________________ Print Name ___________________________________

Notary Public in and for the County and State Aforementioned

My commission expires: _________________________ ATTACH AND INCLUDE THIS PAGE OF NON-COLLUSION AFFIDAVIT OF BIDDER AS PART OF BID FORM; FAILURE TO DO SO SHALL BE CAUSE FOR DISQUALIFICATION OF YOUR BID.


CERTIFICATION OF NONSEGREGATED FACILITIES The Bidder certifies that they do not maintain or provide for their employees any segregated facilities at any of his establishments, and that they do not permit their employees to perform their services at any location, under their control, where segregated facilities are maintained. The Bidder certifies further that they will not maintain or provide for their employees any segregated facilities at any location under they control where segregated facilities are maintained. The Bidder agrees that a breach of this certification will be a violation of the Equal Opportunity clause in any contract resulting from acceptance of this Bid. As used in this certification, the term "segregated facilities" means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms and other storage and dressing areas, parking lots, drinking fountains, recreation or entertainment area, transportation and housing facilities provided for employees which are segregated by explicit directive, or are in fact segregated on the basis of race, color, religious disability or national origin, because of habit, local custom, or otherwise. The Bidder agrees that (except where they have obtained identical certifications from proposed subcontractors for specific time periods) they will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause, and that he will retain such certifications in his files. The nondiscriminatory guidelines as promulgated in Section 202, Executive Order 11246, and as amended by Executive Order 11375 and as amended, relative to Equal Opportunity for all persons and implementations of rules and regulations prescribed by the United States Secretary of Labor are incorporated herein. Date:________________________________ By:____________________________________ Print Name: ____________________________ Official Address: Title:__________________________________ _____________________________________ _____________________________________ _____________________________________ (Include Zip Code) ATTACH AND INCLUDE THIS PAGE AS PART OF BID FORM; FAILURE TO DO MAY BE CAUSE FOR DISQUALIFICATION OF YOUR BID.

CERTIFICATION OF NONSEGREGATED FACILITIES 00310-1 December 2009 ITB-U-10-03



SECTION 00330

DRUG-FREE WORK PLACE FORM

The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that ___________________________________________does: (Name of Business) 1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing,

possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

2. Inform employees about the dangers of drug abuse in the workplace, the business’s policy of

maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations.

3. Give each employee engaged in providing the commodities or contractual services that are proposed a

copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notify the employees that, as a condition of working on the

commodities or contractual services that are under proposal, the employee will propose by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contender to, any violation of Chapter 893, Florida Statutes, or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction.

5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation

program if such is available in the employee’s community, by any employee who is so convicted. 6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of the

matters set forth above. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. Signature Firm Date

END OF SECTION

Drug Free Work Place 00330-1 ITB-U-10-03 – Water Treatment Plant No. 1 – Backwash Water Piping Replacement

SECTION 00335

CONFLICT OF INTEREST STATEMENT

STATE OF FLORIDA ) ) ss CITY OF ____________________ )

Before me, the undersigned authority, personally appeared ____________________________________,

who was duly sworn, deposes, and states:

1. I am the ___________________________ of __________________________________ with a

local office in ______________________ and principal office in ________________________________.

2. The above named entity is submitting an Expression of Interest for the City of Palm Coast

project described as ITB-U-10-03 – Water Treatment Plant No. 1 – Backwash Water Piping Replacement

3. The Affiant has made diligent inquiry and provides the information contained in this Affidavit

based upon his own knowledge.

4. The Affiant states that only one submittal for the above project is being submitted and that the

above named entity has no financial interest in other entities submitting proposals for the same project.

5. Neither the Affiant nor the above named entity has directly or indirectly entered into any

agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive pricing in

connection with the entity's submittal for the above project. This statement restricts the discussion of pricing

data until the completion of negotiations and execution of the Agreement for this project.

6. Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or

otherwise ineligible from participating in contract lettings by any local, state, or federal agency.

7. Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict

of interest due to any other clients, contracts, or property interests for this project.

Conflict of Interest Statement 00335-1

ITB-U-10-03 – Water Treatment Plant No. 1 – Backwash Water Piping Replacement

Conflict of Interest Statement 00335-2


8. I certify that no member of the entity's ownership, management, or staff has a vested interest in

any aspect of or Department of City of Palm Coast.

9. I certify that no member of the entity's ownership or management is presently applying for an

employee position or actively seeking an elected position with City of Palm Coast.

10. In the event that a conflict of interest is identified in the provision of services, I, on behalf of the

above named entity, will immediately notify City of Palm Coast in writing.

_______________________________________ Signature of Affiant The foregoing instrument was acknowledged before me this _____day of ______________, 20_____, by Affiant who is personally known to me _______or who has produced _________________________________ identification. _____________________________________________________ Notary Public Signature Print/Stamp Name ______________________________________

Notary Public in and for the County and State Aforementioned My commission expires:_________________________

END OF SECTION

SECTION 00336

COMPLIANCE WITH THE PUBLIC RECORDS LAW Upon award recommendation or ten (10) days after receiving, submittals become "public records" and shall be subject to public disclosure consistent with Chapter 119, Florida Statutes. Proposers must invoke the exemptions to disclosure provided by law in the response to the solicitation, and must identify the data or other materials to be protected, and must state the reasons why such exclusion from public disclosure is necessary. The submission of a proposal authorizes release of your firm’s credit data to City of Palm Coast. If the company submits information exempt from public disclosure, the company must identify with specificity which pages/paragraphs of their bid/proposal package are exempt from the Public Records Act, identifying the specific exemption section that applies to each. The protected information must be submitted to the City in a separate envelope marked accordingly. By submitting a response to this solicitation, the company agrees to defend the City in the event we are forced to litigate the public records status of the company’s documents. Company Name: _______________________________________________________ Authorized representative (printed): ________________________________________ Authorized representative (signature): ______________________________________ Date: ______________________________ Project Number: ITB-U-10-03 – Water Treatment Plant No. 1 – Backwash Water Piping Replacement

THIS FORM MUST BE COMPLETED AND RETURNED WITH YOUR PROPOSAL

Compliance with Public Records Law 00336-1


SECTION 00337

AMERICANS WITH DISABILITIES ACT AFFIDAVIT The undersigned CONTRACTOR swears that the information herein contained is true and correct and that none of the information supplied was for the purpose of defrauding CITY. The CONTRACTOR will not discriminate against any employee or applicant for employment because of physical or mental handicap in regard to any position for which the employee or applicant for employment is qualified. The CONTRACTOR agrees to comply with the rules, regulations and relevant orders issued pursuant to the Americans with Disabilities Act (ADA), 42 USC s. 12101 et seq. It is understood that in no event shall the CITY be held liable for the actions or omissions of the CONTRACTOR or any other party or parties to the Agreement for failure to comply with the ADA. The CONTRACTOR agrees to hold harmless and indemnify the CITY, its agents, officers or employees from any and all claims, demands, debts, liabilities or causes of action of every kind or character, whether in law or equity, resulting from the CONTRACTOR's acts or omissions in connection with the ADA. CONTRACTOR: __________________________________________ Signature: __________________________________________ Printed Name: __________________________________________ Title: __________________________________________ Date: __________________________________________ Affix Corporate Seal STATE OF ) ) ss COUNTY OF ) The foregoing instrument was acknowledged before me this ___________ day of_________________, 20____, by___________________________________ of __________________________________________________ (firm), on behalf of the firm. He/She is personally known to me or has produced _______________________________________ identification. _____________________________________________ Print Name ___________________________________ Notary Public in and for the County and State Aforementioned My commission expires:_________________________

END OF SECTION

Americans with Disabilities Act Affidavit 00337-1

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