271-22 Attachment-SUBMISSION.pdf

TOWNSHIP OF WEST ORANGE ICKHOLDER D: toertify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned, I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. “ PLEASE CHECK TYPE OF BUSINESS ORGANIZATION: Partnership ____Limited Partnership ____Limited Liability Corp ____ Corporation ___ Sole Proprietorship \/ Limited Uability Partnership __ SubchapterSCorp PLEASE CHECK APPROPRIATE BOXES AND SIGN BELOW Name: Ean OVluvin Home Address: Ce" Old S0heo| ZA Blavstwum » AT 01 bas Stockholders Name: Home Address: Name, Home Address; En livid / iwher Owner or Representative Signature Print Name & Tittef NOTORY PUBLIC Sworn before NIGOLE J. PRIESTNER Commission # 50085320 Notary Public, State of New Jersey My Commission Expires February 22, 2027 Page | 19

TOWNSHIP OF WEST ORANGE NON-CONFLICT OF INTEREST CERTIFICATION REQUEST FOR QUALIFICATIONS FOR Protessiong/ Services , WUT Tree Expert (Title of RFQ) The undersigned certifies to the Township of West Orange, County of Essex, State of New Jersey that in perfomming services to the Township he/she is aware of no circumstance that ‘would constitute a conflict of interest, financial or otherwise, between him/her (ar his/her firm) and the interests of the Township. The undersigned certifies that he/she has made a search of his/her firm’s client base and has executed this certification subsequent to such. search, The undersigned acknowledges this a continuing certification, and shall remain in effect for the term of the services contained in the solicited request for qualifications. certify that the foregoing statements made by me are true and accurate to my personal knowledge; J am making this certification in good faith. I arn aware that if any of the foregoing statements made by me are false, the Board is free to tamninate any professional service agreement entered into with the undersigned and/or his or her finn. Certifying Official: PRINTNAME: Van Di lluvte SIGNED BY: Cuan LL a TITLE: Owner DATE: 6/99 PQ Page | 20

Note: A separate resume can be attached. 1. Please provide the name and address of Names and roles of the individuals who will perform the services and description of their education, municipal experience and experience with projects similar to the services contained herein including their education, degrees and certifications, Please. see alfathed. 2. — References and record of success of same or similar service. Please see aftached. Page | 21

7 } i 3. Description of ability to provide the services in a timely fashion (including staffing, familiarity and location of key staff. Please See alteched - 4. Cost details, including the hourly rates of each of the individuals who will perform services, and all expenses: Plea se See attached. Authorized Representative. Evan Delf uvilo (print name) Authorized Representative. an Lili (ignature) FAX # Page | 22

of the Revised General Ordinances of the Township of West Orange Pursuant to Section 2-68.1 of the Revised General Ordinances of the Township of West Orange, please set forth below all political contributions in cash or in kind of two hundred ($200.00) dollars or more made within five (5) years of the date of acceptance of a proposal for a negotiated contract with the Township of West Orange, or within five (5) years of the notice of award for a bid contract with the Township of West Orange, either directly or indirectly, by the individuals or any of the principals of the business entity completing this form or by the business entity itself, to any elected official of the Township of West Orange currently in office or any political organization affiliated with an elected official of the Township currently in office. The current elected officials of the Township include the following: Mayor Robert D. Parisi; Councilwoman Susan McCartney; Councilwoman Cindy Matute Brown; Councilman Bill Rutherford; Councilwoman Tammy Williams; and Councilwoman Michelle Casalino. Name of Contributor Amount Recipient of Contribution Contribution Date 'f you have NOT made any contributions within the scope of Section 2-68.1, as set forth above, please indicate here § AvVe@vve | hereby certify under penalty of perjury that the information provided herein is true and accurate to the best of my knowledge, information and belief. Print Name: Zvan Difluyro Company: ED Arbortsts and facesters Signature _ Page | 23

TOWNSHIP OF WEST ORANGE ACKNOWLEDGMENT OF RECEIPT OF ADDENDA The undersigned Bidder hereby acknowledges receipt of the following addenda: | Please assign the number, date and initial. i Addendum Number Dated Acknowledge Receipt _( Initial) TS INo addenda was received. : Acknowledged for; ED Avboriety and foves ters (Company Name) By: Doo. FMD (Signature of Authorized Representative) Name van _Dilluvire (Print) Title: (6) wine Date: a 68/2 Page | 24

TOWNSHIP OF WEST ORANGE DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN Proposer: En Dillaviio Pursuant to Public Law 2012, c. 25, any person or entity that submits a bid or proposal or otherwise proposes to enter into or renew a contract must complete the certification below to attest, under penalty of perjury, that the person or entity, or one of the person or entity’s parents, subsidiaries, or affiliates, is not identified on a list created and maintained by the New Jersey Department of the Treasury as a person or entity engaging in investment activities in Iran. If the Director finds a person or entity to be in violation of the principles which are the subject of this law, s/he shall take action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring, declaring the party in default and seeking debarment or suspension of the person or entity. I certify, pursuant to Public Law 2012, c. 25, that the person or entity listed above for which | am authorized to submit a proposal: Must check appropriate boxes Is not providing goods or services of $20,000,000 or more in the energy sector of iran, including a person or entity that provides oil or liquefied natural gas tankers, or products used to construct or maintain pipelines used to transport oil or liquefied natural gas, for the energy sector of Iran, and ls not a financial institution that extends $20,000,000 or more in credit to another person or entity, for 45 days, or more, if that person or entity will use the credit to provide goods or services in the energy sector in Iran. In the event that a person or entity is unable to make the above certification because it or one of its parents, subsidiaries, or affiliates has engaged in the above referenced activities, a detailed, accurate and precise description of the activities must be provided in part 2 below to the New Jersey Tumpike Authority under penalty of perjury. Failure to provide such will result in the proposal being rendered as non- responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by law. Part 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, accurate and precise description of the activities of the proposer, or one of its parents, subsidiaries

OVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, accurate and precise description of the activities of the proposer, or one of its parents, subsidiaries or affiliates, engaging in the investment activities in Iran outlined above by completing the boxes below. Name: Relationship to Proposer: Description of Activities: Duration of Engagement: Proposer Contact Name: __ Page | 25

' | i Certification: |, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. | attest that | am authorized to execute this certification on behalf of the above referenced person or entity. | acknowledge that the Township of West Orange, State of NewJersey is relying on the information contained herein and thereby acknowledge that | am under a continuing obligation from the date of this certification through the completion of any contracts with the Township to notify the Township in writing of any changes to the answers of information contained herein. | acknowledge that f am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if | do so, | recognize that | am subject tocriminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Township of West Orange, State of New Jersey and that the Township at its option may declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): Evan Dilluvrw — signature: _ Lrert Mla) a Title: Qusner pate: 6-/2& [AA Page | 26

Business Registration Certification and Public Works Contractor Registration Certification Effective September 1, 2004, the State has expanded its Contractor Registration Program to focal Government contracts, P.L_ 2004, c57. All business organizations that do business with a local government agency are required to be registered with the State. The business must provide proof of that registration to the local government agency before that local government agency can enter into a contract with the business. A copy of the Business Registration Certificate must also be on file before any purchase order/voucher or other contracting document can be issued. Contractors are responsible for notifying subcontractors. Further information and registration can be obtained online from the NJTreasury, Division of Revenue or by calling (609) 292-1730. KAKA RRA KR RRA KR IRE IRR IO, PLL. 1999 Chapter 238, The Public Works Contractor Registration Act specifies that no contractor or subcontractor shall bid on or engage in any contract (or part thereof) for public work which is subject to the provisions of the “New Jersey Prevailing Wage Act”, P.L. 1963 C. 150 (c. 34:11-56.25 et seq.) for the construction, reconstruction, demolition, alteration, repair, or maintenance of a public building regularly open to and used by the general public or public institution, and includes any subcontractor or lower tier subcontractor of a contractor unless they are registered with the Commissioner of Labor. Page | 27