ATTACHMENT 5 BID/BIDDER CERTIFICATION SHEET

Invitation For Bid IFB Number l 1A2687

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 11required attachments" as an entire package with Qiiginal signatures. The bid must be transmitted in a sealed envelope in accordance with IFB instructions.

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

demonstrating that I 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-<lay period.

An Unsigned Bid/Bidder Certification Sheet May Be Cau§e for Bid Reiection

1. Company Name

SJ 2b. Email Address

3. Address

Indicate your organization type:

2. Telephone Number la. Fax Number

[160)rl. I 3 5f 6;;

4. D Sole Proprietorship I 5. D Partnership I 6. J:? Corporation

Indicate the applicable employee and/or corporation number: 7. Federal Employee ID No. (FEIN) 2µ / ~ b 6 6 5 I 8. California Corporation No.

Indicate the Department oflndustrial Relations information: 9. Contractor Registration Number I -.. O 00 0 0 ~ 1(~ ( Indicate applicable license and/or certification information: 10. Contractor's State Licensing

Board Number

12. Bidder' Name (Print)

14. Signature

11. PUC License Number CAL-T-

13. Title <

15. Date

16. Are you certified with the Department _of General Services, Office of Small Business and Disabled Veteran Business Enterprise Services (OSDS) as: a. Small Business Enterprise If yes, enter certification number:

Yes (Z1 No D

/O't ?fOI

b. Disabled Veteran Business Ei1terprise Yes D No [2f If yes, enter ymir 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 Non-Small Business committing to the use of 25% Certified Small Business Subcontractor Participation? Yes D No D

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

\

STATE OF CALIFORNIA · DEPARTMENT OF TRA._NSPORTATION

BID PROPOSAL ADM-1412 (REV, 1 l/2015}

ATTACHMENT 1 CONTRACTOR'S NAME (Please Print); CONTRACT NO.

ITEM ESTIMATED UNIT OF ITEM

NO. QUA..NTITY MEASURE

Cost per hour/per person 1 21,000 (total hours) Per l!our (based on a five (5) person crew)

as described in Exhibit A, Scope ofWork (SOW)

(I) THE ABOVE QUANTITIES ARE ESTIMATES ONLY AND ARE GiVEN AS A BASIS FOR COMPARISON OF BIDS. NO GUARANTEE JS MADE OR IMPLIED AS TO THE EXACT QUANTin' THAT WILL BE NEEDED.

(2) IN CASE OF DlSCREPANCY BETWEEN TiiE UNIT PRICE AND TIIE TOTAL SET FORTH FOR A UNIT BASIS ITEM, THE UNIT PRlCE SHALL PREVAIL

·uNITPRICE ( Price Per Unit of

Measure)

$ 39 ()y

TOTAL THIS PROPOSAL

Invitation For Bid IFB Number 11 A2687

Page 1 of 1

TOTAL (Estimated Quantity X Unit

Price)

$ i10 oo 0

$ YI 0 000

...... , ...... ·.-------'-~~~~-~---=---------

Sta\e of California----Depan:ment of G1meral Services, Procurement Division

GSPD-05-105 {REV 08/09)

ATTACHMENT2 invitation For Bid

IFB Number 11A2687 Page 1 of2

BIDDER DECLARATION

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

a. Identify current Cal ifomia certification(s} (MB.-SB, ~SA, DWEJ: 5 !3 or None LJ (If "None! go to Item #2)

b. Will subcontractors be used for this contract? YesJZJ No D {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 vehides that will deliver the products to the State, identify which solicited services your firm will perform, etcJ Use additional sheets, as necessary.

A-n IN D \' K. d..o $C.rv ( bet{ I}'\ ~ 'x "'"d'.); f- A .s fit,_ ~ ~ d f v,.J th' K.. t YI/'( I VU,( J /, J-1-e,., JP ( ( t u wlt\,cl-i wdf h.t . --A.R__ b V&t

c. If you are a California certified DVBE: (1) Are you a broker or agent? Yes D No (2) If the contract !nciudes equipment rental, does (olr COE:rny ~at least 51 % of the equipment provided in this contract (quantity and value}? Yes No N/AJL_l

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

Subcontractor Name,Contact Person, Subcontractor Address CA Certification (MB,SB, Work performed or goods provided Corresponding Good 51% Phone Number & Fax Number & Email Address NVSA, DVB£ or None) for this contract % of bid price Standing? Rental?

f .f\fy,ot ~,, s.n (5 3o4'1 q 56' Voie St- l:>VS& Pr--a,n,-t. ~"' s.r 1h st c.~fllO.f\\j Lil b,,.,. hJ b Sc.i o _f- woY~ l2J D 1\-3,f ~~I bAle Ml{r,-e~ 17 ~ 5J.. 5J. a.s ~ ...,_~ f~ "'i,:,1,;t ~ ~/,,

CA .. . '

yct-o -- 390 -5t f5 ,, G .(J) ~l'M.Ov_.( la.fk.i- a t.tt.li16

.. 01)-56 5 __ Wl rDMS ,Jt.s._, ft"'c.t. t,~s, - .. ··- ... ---··-··----- ·- ··-·· ·-· ······--~~--~---· ...•. ,., ..

d~L~ .S'f,-Je...,_s.

D D

D D !

------· .. - -.. -.. -·-·-' --------- --- -- -- . _J_. __ -------- --- -------- ------- ----·---------- -------- ' •-·-·~•••-•ru .. ·••-•••~

• 1,..t~?::"..?'=ii' ...... :a:r.;:~..- .......... •--,., ........ x ... ;a""";L+~rn.=.,.. 2..,..:::n:.;~.~~ ........ , ............. n-:V¼e:t..~.,~~4""x----:-"'l:.~·'L~=--, -=-,.;,· ~==mr=a~, .. ...,.._.....,......,...,.._,......-,.rm~~'IC=""'"'i,,,_,_,_,,,,......,_,,_......,......., _______ ~ ' ' '

CERlffift<C.I\TmN i l't:'f s!gnengi tnlli' btd i·e-sp,.mse, R ce5'tcf:, mtdler penaalty of perjllleytnat the information provided is true and correct.

, • AA{~-.,..- ,1rr~1,, - · Page _l ___ of _:2 __ _

...... · --···-·-· .. ····--- ·-·-·- ·---········-·---~ ... , ........ ..,. __ _.__ ____ ~~- -~-- ~-:,..,.-1=-;,-----=~-· ....... ~---

ATTACHMENT 11 STATE OF CALIFORNIA- DEPARTMENT OF GENERAL SERVICES PROCUREMENT DIVISION

DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

lnvita1ion For Bid !FB Number l I A26X7

Page I of 1

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: f 11. f>.,o r Lo 1 'j h. cs DVBE Ref. Number: -----~

Description (materials/supplies/services/equipment proposed): 4.~uV1S vul;-tl ~ ,j/1'.1 -h, ~;.r>v.(.. 4 ,!:\~f Jitt-t: r, 7....- C .S-e.A- ~ f-, ~ .t"u, f n,vi I "' ~ IQ' IL )

Solicitation/Contract Number: I/ It)-G f r SCP RS Ref. Number: __________ _ (FOR STATE USE ONLY)

SECTION 2

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

.[Zf 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 suffi

(Printed Name oDV 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)

(Print or Type Name)

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

(Date Signed)

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 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 s ignature blocks for each person to sign) :

(Printed Name) (Signature) (Date Signed)

(Address of Owner) (Telephone) (Tax ldentifica1ion Number of Owner)

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

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

Page _ ._ of _._ .

Patriot Logistics

30449 Savoie St

Murrieta, CA 92563

(800) 390-5685

DVBE No. 1785252

DIR No. 1000051690

CUSTOMER NAME & ADDRESS

Singh Group Inc. 1308 Descanso Ave San Marcos, CA 92069

PROJECT NAME

11A2687

DESCRIPTION

Provide supervision, labor equip-ment and supplies to accomplish scope of work as stated in Exhibit A, 5(7) "Remove litter & debris from roadsides, fence lines, & drainage system."

* Please note this work does not require a contractors license C27 because it is janitorial or clean up work that we are performing

(Patriot Logistics has 100% owner-ship of the services provided under this contract as per VA Code MVC 999.2(b)(l). Patriot Logistics also states that it is not a broker or agent as stated in MVC999.2(b)(l)

Accepted

Lo: istics

DATE

12/19/2017

EST. QTY UNIT OF MEASURE

1365 Hourly

BILL TO

Singh Group Inc. 1308 Descanso Ave San Marcos, CA 92069

QUOTE NO.

2745

QUOTE

UNIT PRICE TOTAL

$ 30.00 $ 40,950.00

Total $ 40,950.00

DISABLED VETERAN

D 'v BE BUSINESS ENTERPRISE

DVUE i'\n.: 1783751