238-25 Exhibit B.pdf

Hist of Agencies with Elected Officials Required for Political Contribution Disclosure NAIS.A. 19:44A-20,26 County Name: Essex State; Governor Legislative District #5: 26, 27, 28, 29, 34, & 40 State Senator and two members of the General Assembly per district, County: County Commissioners County Clerk Sheriff County Executive Surrogate Registrar of Deeds Municipalities (Mayor and members of governing body, regardless of title): Belleviiie Township trvington Township Orange City Bloomfleld Township Livingston Township Roseland Borough Caldwell Borough Maplewood Township South Orange Village dat Grove. Township... __. _Milfourn Township. . _ _ _. _. _ .... Verona Township st-Orange:Clty———_———"Montclair-township———_——— West Caldwell Towrrsht oo Errer Petts Toms Newark City ‘West Orange townstip SSS Faltield-Townshie- North-Caldwall Borough Glen Ridge Borough Nutley Tewnship Boards of Education (Members of the Baard): Belleville Town Bloomfield Township Caldwell-West Caldwell Cedar Grove Township Essex Fells Borough Fairfleld Townsh |p Glen Ridge Borough Irvington Township Livingston Township Millburn Township Newark City North Caldwe!l Borough Nutley Town Roseland Borough South Orange-Maplewood Verona Borough West Essex Regional West Orange Town Fire Districts (Board of Fire Commissioners); NONE 17

a i i] t STATEMENT OF OWNERSHIP DISCLOSURE NLS.A, 52:25-24,2 (PL, 1977, ¢.33, as amended by P.L. 2016, 0,43) This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure Co subutit the required information is cause for automatic rejection of the bid or proposal, Name of Organization: & KA BOWS tt Cons TUTE AS, ine Organization Address: tt 6 UO CTNAIELD AVE, WAT OLRUG &, uf 6 1082, Part I Cheek the box that represents the type of business organization: ia Sole Proprietorship (skip Parts 1 and 1, execute certification in Part 1V) CI non-Prot Corporation (skip Parts IT and II, execute certification in Part TV) Eafcr-prott Corporation (any type) Dr rimited Liability Company (LLC) EI eartnersti Ip . CTimited Partnership DA cinitea Liability Parinership (LLP) Dother (be specific): ii The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, cr of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION) OR O No one stockholder in the corporation owns 10 percent or more of its stock, of atty class, or no individual partner in the partnership owns a 10 percent ot greater interest therein, or no member in the limited lability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV) (Please attach additional sheets if more space is needed): Name of Individuat or Business Entity Address » CAPO BAA ST Cle0n WWE Sona CG EAB CUE WET OMe, NP 67052. ; Koen KS STEPH GCAOGiSK Ae a One Bo S{ taoken AVE Hor. & GeAGOWS WEST OLALEE, UF O708 1 18

i Part IT DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART I If'a bidder has 2 direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greafor beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater betieficial interest in the publicly traded parent entity, along with the relevant page 1umbets of the filing(s) that contain the information on each such person, Attach additional sheets if more space is needed, Website (URL) containing the last annual SEC (or foreign equivalent) fling Page #’s Please list the names and addresses of each stockholder, pariner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part I other than for any publicly traded parent entities referenced above. ‘The disclosure shall be continued until names and, addresses of every.non-corporate, stackhalder, and individual pattner,.and.member-sxceeding.the.10 ..- . percent-ownership-criterta-established-pursuant-to-Na:Sat92125-24;2 lias been-listed Attach additional gheets————— if more space is needed, | _ Stockholder/Partner/Member ane Address Corresponding Entity Listed in Part II : Part IV Certification I, being duly swern upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. | acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that the Township of West Orange is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with Township of West Orange to notify the Township of West Orange in writing of any changes to the information contained herein; that Iam aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if! do so, 1am subject to criminal prosecution

the information contained herein; that Iam aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if! do so, 1am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the Towaship of West Orange to declare any contract(s) resulting from this certification vold and unenforceable, FullName (prey: |PAgL lL Gekbowees Tite: | PES Hiay Signature: 4A ri Kaahourt bate: | Ocr DBE. 8 Zo25° 32

BUSINESS REGISTRATION CERTIFICATION AND PUBLIC WORKS CONTRACTOR REGISTRATION CERTIFICATION Effective September 1, 2004, the State has expanded its Contractor Registration Program to local Government contracts, P.L, 2004, 57. 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/youcher' or other contracting document can be issued, Contractors are responsible for notifying subcontractors, Euatherinformatih dueaistral be-abiainedoonit r zistral fe verue=or=by-cablinrp=(609). ES JOGO tk P.L, 1999 Chapter 238. The Public Works Contractor Registration Act specifics that no contractor or subcontractor shall bid on or engage-in any contract (or part thereef) for public work whicli is subject to the provisions of the "New Jersey Prevailing Wage Act", P.L. 1963 C, 150 (c. 34:11-56.25 et seq.) Yor 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 inchades any subcontractor or lower tier subcontractor of a contractor unless they are registered with the Commissioner of Labor. 33

CERTIFICATION OF NON-INVOLVEMENT IN PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS Pursuant to N.J,S.A. 52:32-60,1, et seq, (2022, ¢. 3) any person or enllty (hereinafter "Vendor'") that seeks to enter Into or renew a cont‘acl with a State agenoy for the provision of goods or services, or the purohase of bonds or other obligations, must complete the certification below indicating whether or nat the Vendor is Identified on the Office of Forsign Assets Goatrol (QFAC) Specially Designated Nationals and Blocked Persons ist, available —_ here; Allpsiieanolousssareh oftedan oN, If the Department of the Treasury finds that ¢ Vendor has made a gariifloation In violation of the law, It shell take any aation as may be appropriate and provided by law, rule or contract, Including but fot limited to, imposing sanations, séeking compliance, recovering damages, declaring the party IN default and seeking debarment or suspension of the party, |, the undersigned, certify that | have read the definition of *Vendor™ below, and have reviewed the Office of Foreign Assats Gontro] (OFAC) Specially Designated Nationals and Slocked Persons list, and having dona so odrtify; (Gheok the Appropriate Box) a, Thal the Vendor is not Identified on the OFAC Suectally Desianaled Nationals ued Gloaked Parsons list op OR That | am unable to certify as to “A® above, because the Venclor Is {dentified on the OFAC. Specially . -Rgslonatad Nationals and. Blocked Parsons lielon account of activity ralaved.te Russia andlor Belarus. —.— — ft “That--am-unable-to-cartify-as-to-"A-above, because the Vendor Is-Identified-on- the a .) 6. ded Parsoris list, However, the Vendor is engaged In aailvily related lo Russia and/or Belarus consistent with fecisral law, regulatlon, floense or exemption. A detailed description of how the Vendor's activity related to Russia and/or Balarus Is consistent with federal law Is set forth below. (Atfaoh Additional Shoals # Nocassary,) Kotouabe exxrobce 6 Cots TIgpalure of Vendars Authorized Representative Daje AOL. LAB OWLS C4 Ba ~ aS FF Sid. Tlie Name abd Tile of Vanor's Aulhorizad Roprosarfalive Vgndors FEIN CABOWS LA COMSLLCTIOM [Kc DIA BI{- bit; wao) ay D CF! Ao Ad C Or a Number WAT OWES Nf o70&> Construct on Ft O@VErizan, NE} Vendors Address {City/State/Zip Cade) Vendor's Email Address ‘Vendor moans: (1) A natural person, corporation, company, tinited

Ao Ad C Or a Number WAT OWES Nf o70&> Construct on Ft O@VErizan, NE} Vendors Address {City/State/Zip Cade) Vendor's Email Address ‘Vendor moans: (1) A natural person, corporation, company, tinited partnership, limited lablity partnership, Enited Ueblity cormpany, business association, sole proprietorship, Jolnt venti, partnarship, soclety, trust, of any olhor nofigaverwmental entity, organizallon, at group; (2) Any governmental entity of instrutmontality of a government, Including & multatoral development institution, as defined in Sactlon 1701(0)(8) of tie thiemational Financial Institutions Act, 22 U.S.C, 262r(0}'S}, or (3) Any parent, successor, subuni, diract or Indlract subsidiary, of any entity onder common o¥marship or control with, any entity desoribed in paragraph (1) or (2). WaRev. 1.22,2024 34

SITE INSPECTION AFFIDAVIT 4 PAL L FAB OWSEH on behalf of the bidder, QtA BOLE ICT COSTE LCTTON, hE do hereby declare that, I or my duly authorized representative, did satisfactorily inspect the project limits for the purpose of being fully informed as to the locations and conditions of the various Sidewalks, Paths, Crosswalk and Bus Shelters and Stops within the ‘Township of West Orange for snow removal to be cleared under this contract. 1 inspected the various sites on the STH day of CCTOBEY. BOAT and] hereby acknowledge that I have satisfied myself regarding the conditions of the various sites and the nature and extent of the worket = formrec-underctht: + 7 ‘Hots £) f- od == ay PROL GREBOUSE! fl Z Yidbaudl (Print or type name) QLADOUSEL COUSTEUCTION, (Rec. (Bidding Firm/Contractor) ——-—-—Subseribed-and-sworn a Sworn before me this “4, day of Gels 2095 . SOD (Notary Public) My commission expires on Aye bpro_. Dylan Drummond "enc teas” Expires: Auguat 13, 2030 ' 35

i 4 t NWJS.A, 40A:11-2.4 q NLS.A, 18A:18A-49.4 YIN Mandatory Optional NIA \ Goods and j LPcL Y Services x PSCL . Y | Construction x 1 P.L, 2042, ¢.25 prohibits the awarding of State and local public contracts for .goods-and-serices-with-persens-or-entities-engaging-In-certain-investment—_-—-____ activities in-energy Rance sectors of iran, Prior to contract award, vandors and contractors_must certify that nelther-they-nor-eany-parententity-subsidiary-or-——— ffiiate is listed’on the New Jersey Department of the Treasury’s list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L, 2012, c, 25 (“Chapter 26 List"). The Certification form requires the Insertion of contracting unlt Identification Information which should be filled in (in Italics on the form) prior to tts use. 36

Person or Entity = | COMPLETE PARI t BY CHECKING EITHER BOX, Pursuant to: Public Law 2022, .¢. 23, afly: piorson.or entity that'is. a suecessfill bidder or proposer, or identified -o investinent . The lst is found . on: » ‘Treasury's. website. at soww.slate.n}.us/treasury/pirchase/pdl/Chapter25Listpdf, 7 The Chapter 25 tist must be teviewed prior to completing tHe below certification, Ha vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may provided. by law, role or contract, Inchuding but not limited to dinposing sanctions, seeking compliance, redoveting damages, declaring the: partyin default and seeking debarment or'suspension of the party, . E certify, pursuant to Public Law 2012, ¢. 25, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate thereof is listed on the oa Nl. Department of the Treasury's list of entities determined to be engaged in | prohibited activities in Tran pursuant to PL, 2012, ¢. a5 ("Chapter 25 List"), £ further certify that I am the person listed above, or I am an officer or represenialive of the entity listed above _and_om authorized to_make_this certification on tis behalf, Iwill skip Part 2 and sign and complete the Certification below, Jam unable to certify as above because the person or entity and/or a parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury's Chapter 25 list, Iwill provide a detailed, accurate and precise description of the O activities in Part 2 below sign and complete the Certification below. a7