261-25 Cerbo Submission.pdf

fine imposed by ELEC in an amount to be determined by the Commission which may be based upon the amount that the business entity failed to report. The enclosed list of agencies is provided to assist the contractor in identifying those public agencies whose elected official and/or candidate campaign committees are affected by the disclosure requirement. It is the contractor's responsibility to identify the specific committees to which contributions may have been made and need to be disclosed. The disclosed information may exceed the minimum requirement. The enclosed form, a content-consistent facsimile, or an electronic data file containing the required details (along with a signed cover sheet) may be used as the contractors submission and is disclosable to the public under the Open Public Records Act. 88

The contractor must also complete the attached Ownership Disclosure Certification. This will assist the agency in meeting its obligations under the law. NOTE: This section does not apply to Board of Education contracts. 89

C.271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. 19:444-20.26 This form or its permitted facsimile must be submitted to the local unit no later than 10 days prior to the award of the contract. Part |—Vendor Information Ve di ay * Name: Ces Phe SP ony Cece gHouses, Caw Address: | 4/79 Litt ton Rod, City: [Py x2! Paws LNW State: | Zip. o7ds7 The undersigned being authorized to certify, hereby certifies that the submission provided herein represents compliance with the provisions of N.J.S.A. 19:44A4-20.26 and as represented by the Instructions accompanying this form. 4p {/ 7 : Q Signature 2 tinted Name Cath ‘o (peg Title y : ¢- Part (4 Contributior’ Disclosure ‘ Disclosure requirement: Pursuant to N.J.S.A. 19:44A-20.26 this disclosure must include all reportable political contributions (more than $200 per election cycle) over the 12 months prior to submission to the committees of the government entities listed on the form provided by the local unit. [1] Check here if disclosure is provided in electronic form. Contributor Name Recipient Name Date Dollar Amount 2 $ \ WA I\ “| yt 90

Continuation Page C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. 19:44A-20.26 Page ___ of Vendor Name: Contributor Name Recipient Name Date Dollar Amount $ : i] i : i | ptf} A r AT —} | | OL

List of Agencies with Elected Officials Required for Political Contribution Disclosure N.J.S.A. 19:444-20.26 County Name: Essex State: Governor Legislative District #s: 26, 27, 28, 29, 34, & 40 State Senator and two members of the General Assembly per district. County: County Commissioners County Clerk County Executive Surrogate Sheriff Registrar of Deeds Municipalities (Mayor and members of governing body, regardless of title): Belleville Township Bloomfield Township Caldweli Borough Cedar Grove Township East Orange City Irvington Township Livingston Township Maplewood Township Millburn Township Montclair Township Orange City Roseland Borough South Orange Village Verona Township West Caldwell Township. Boards of Education (Members of the Board): Belleville Town Bloomfield Township Caldwell-West Caldwell Cedar Grove Township Essex Fells Township Newark City ‘West Orange Township —_____—_______—Fairfield-Township. North Caldwell Borough Glen Ridge Borough Nutley Township Essex Fells Borough Fairfield Township Glen Ridge Borough Irvington Township Livingston Township Millburn Township Newark City North Caldwell Borough Nutley Town, Roseland Borough South Orange Maplewood Verona Borough West Essex Regional West Orange Town Fire Districts (Board of Fire Commissioners): NONE 92

NON-COLLUSION AFFIDAVI TOWNSHIP OF WEST ORANGE COUNTY OF ESSEX Cyan Ca ous of the (Township, City, Town, Township) of Pagssppany in the County of gee ts ‘ re ‘ and the State of N ne of full age, being duly sworn according to law on my oath depose and say that: + “7 = lam V- Z of the firm of CER Ba! Facsygean/ OEE thew Oe . oENe. ‘ : The Bidder making the Proposal for the above named Project, and that | executed the said Proposal [ with full authority so to do; that said Bidder has not, directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free, competitive bidding in connection with the above named Project; and that all statements contained in said Proposal and relies upon the truth of the statements contained in this affidavit in awarding the Contract for the : said Project, | further warrant that no person or selling agency has been employed or retained to solicit of secure such Contract upon an agreement or understanding for a commission, percentage, brokerage or contingent fee, except bonafide employees or bonafide established commercial or selling agencies maintained by Coeds Paasi Ci) Cocenbsuses. Ene - 4Name of Contractor) opt hea! bpusgae, (NISA. 52:34-15) (Also type or print née of Affiant under signature) Cy piri ~ Caabere Sworm and Subscribed to lObeh before me this Notary Public of Notary Public of New Jersey Commission Expires 1/ 2/2028 My commission expires 93

: CONTRACTOR'S EXPERIENCE STATEMENT The Bidder is requested to state below what work of a similar character to that included in the proposed Contract he has done, and give references that will enable the TOWNSHIP to judge his experience, skill, and business standing. BIDDERS and proposed Subcontractors may be required to submit additional information regarding their respective financial condition prior to the award of the Contract ' DATE PROJECT COMPLETED _LOCATION OWNER CONTRACT AMOUNT NOTE: USE ADDITIONAL SHEETS IF NECESSARY 94

This ‘This ne Ao Ga one Path : PARSTEPANY, Nay CEDKS GOrTGA Le OF AMENGETY {ort} MUSE BO Gree Tay Ssh _astitieae at det ‘xfer wahieg tak is heey alithorizad sRSeY SALES | & USE. TAX . plrhuent WNT. S 8. cee er ste: “Yor tinned paosin athe tot tnt in aay cae af eunerat d STATE OF NEW JERSEY STATE OF NEW JERSEY _ SINESS REGISTRATION CERTIFICATE y _ | Taxpayer Name: ‘| Brade Name: | Addtese: . . + ; - Certificate Number: | Effective Date: J Date of Issuance CERBO'S PARSIPPANY GREENHOUSES,INC. = 440 LITTLETON RD. . PARSIPPANY, NJ 97054-4802 0872310 January 23, 1991 October 01, 2015 i For Office Use Only: . 20151001143540138 -

BUSINESS REGISTRATION CERTIFICATE (Township Requirement) P.L. 2009 ¢315, requires that, effective January 18, 2010, a contracting agency must receive proof of the Bidder’s registration prior to the Award of Contract. The Business Registration Certificate must be obtained by the Bidder prior to the receipt of Bids, however, a Business Registration Certificate is not required in the submission of the Proposal forms for this Contract. If Subcontractors are named on the Bid, proof of the business registration for each must be provided prior to the Award of Contract. The Business Registration Certificate must be obtained by the Subcontractor prior to the receipt of Bids, however, a Business Registration Certificate is not required in the submission of the Proposal forms for this Contract. Proof of business registration shail be: + A copy of a Business Registration Certificate issued by the Department of Treasury, Division of Revenue; or : _Acopy of the web printed version provided by the Division of Revenue BEATE coe Neve seRSHY. BUSINRRS REOTSTHATOR CENTER Abe SiR SMe ABLNEY i i TARA ER TAME: : TAX REGHIMRATION Test abuOURT TARE AYER IORNTIPIGAT ION: ‘anGdbemdieoe : OAS : ATTACH BUSINESS REGISTRATION CERTIFICATE HERE 95

Disclosure of Investment Activities in Iran Person or Entity |-Part 1: Ceitification COMPLETE PART 1 BY. CHECKING EXTHER BOX, Pursuant to Public Law 20 12, ¢. 25, any person of entity that is a successful bidder or proposer, or "otherwise proposes to enter into or renew. a contract, must complete the certification below to attest, “linder penalty of; petjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate ig identified-on the State Department of Treasury's Chapter 25 list as a person or entity engaging in investment..-activities “in Trani The “fist - is found: on: “Treasury’s:.” website’ ~ at wiv. stale. nj. us/tteasurv/nurehase/ed¢Chaptor2S1 ist pdt 4 The Chapier:25 list must: be reviewed ptior to-completing the below. certification. “If a. vendor or - contractor is found to be in violation of law, action may be taken ‘as appropriate and-as may. provided “by law; ruler contract, incliding but"not limited to iniposing” sanctions, seeking compliance, recovering damages, declaring the party in defaulvand: sealing de debarment ot ‘Suspension of the party. I certify, pursuant to Public Law 2012, ¢. 25, that neither the person or entity listed ahove, nor_any parent entity, subsidiary, or_affiliate thereof is_listed_on_the-N.J— activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). I further certify that I am the person listed above, or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf. I will skip Part 2 and sign and complete the Certification below. of Department of the Treasury’s list of entities determined to be engaged in prohibited OR. Lam 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 oO Treasury's Chapter 25 list. I will provide a detailed, accurate and precise description of the activities in Part 2 below sign and complete the Certification below. 96