Township Council Meeting — Packet

STATEMENT OF OWNERSHIP DISCLOSURE N.J.S.A. 52:25-24.2 (PL. 1977, ¢.33, as amended by P.L. 2016, ¢.43) This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal. Name of Organization: Organization Address: Part I Check the box that represents the type of business organization: Dsole Proprietorship (skip Parts II and III, execute certification in Part IV) Dnon-Profit Corporation (skip Parts II and III, execute certification in Part IV) [Xlgor-Profit Corporation (any type) Dimitea Liability Company (LLC) Dbpartnership Cl Limited Partnership CU Limited Liability Partnership (LLP) ‘ Dother (be specific): Part I 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, or 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 Noone stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability 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 Individual or Business Entity Address = ; aw Feclare IB Soe -_-[rofe nine, (hf 2 & Saw) SeLigm 5 Regen Ber rPa Cpa = 7 led y PLT 7 Wf CED P-17

Part II] DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART IL Ifa bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater 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 beneficial interest in the publicly traded parent entity, along with the relevant page numbers 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) filing Page #’s Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every non-corporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-24.2 has been listed. Attach additional sheets if more space is needed. Stockholder/Partner/Member and Address Corresponding Entity Listed in Part II WIKe2 DP tnade SE le - Canny erwin 90m © Part IV Certification I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I 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 I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, P-18

and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the Township of West Orange to declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): Te. . Modr- Title: Dre. Signature: BY) Date: p6/24 124

BIDDER'S AFFIDAVIT State of New Jersey ) )ss: County of ) — xe. p- {No fe deposesghd says: / r 1. Ireside at Loc ke, 2) { Povect s Mwnwe being of full age and being duly sworn, upon his oath - 2. Lam Dy OSs beard of the firm of LTE 7 (Name of Bidder) v 3. | am the person who signed the foregoing Bid and | was duly authorized to execute such Bid, The Bid is a true offer of the Bidder. If the Bidder has a seal, then such seal is affixed to the Bid. All of the statements and declarations contained in the Bid are true to the best of my knowledge and belief. (Seal) Lf a fib Subscribed and sworn t before me this A” day of J “TL bwLaw Zz = Notary Public of the St of New Jersey .~ y KUMAR seion totary Public, SI My ConnlesION: expiredy Com (Notary Seal) P-20

AFFIDAVIT OF NON-COLLUSION The undersigned bidder of full age, being duly sworn according to law depose and hereby specifically certifies that: A. To the best of the bidder's knowledge and belief, the annexed bid proposal for this project has not been prepared in collusion with any other bidder of like item or services and the prices, discounts, terms and conditions thereof have not been directly or indirectly communicated by or on behalf of the bidder to any person other than the recipient of the bid and will not be communicated to any person prior to the official opening of the bid. B. The bidder fully understands that no premiums, rebates, or gratuities are permitted either with, prior to, or after signing of contract. Any violation will result in cancellation and removal from the bid list. Cc. The bidder further certifies that the undersigned has the necessary authority, to sign this stipulation stating that the bidder has not entered into any agreement, or otherwise taken any action in restraint of free competitive bidding in connection with this bid. All references to the bidder are understeod to include the undersigned and all principals, partners and officers of the bidder. i - Date: Vine spf Tne pe (Nate and ES. BST avs an cn Realeral brad! (Address) “> NWinynd, ALL OSS } (Corporate Sea) Subscribed and sworn to before me , this RR pot day of fnwe 20, Notary Seal P-21

BID SECURITY This Proposal is accompanied by bid security in accordance with the conditions stated in the Invitation to Bid. The bid security in the form of: A. Surety Bid Bond B. Certified/Treasurer's check C. Cash the - jount of TD hihys Lh Duty ean LDI) payable to Township of West Orange The Bidder hereby agrees that if this Proposal shall be accepted by the Owner and the Bidder shall fail to execute and deliver the Contract and the required Performance Bond or other required documents in accordance with the requirements of this Proposal and other sections of the Contract Documents within the time specified, then the Bidder shall be deemed to have abandoned the Contract and thereupon the Proposal and acceptance shall be null and void and the security accompanying the Proposal shall be forfeited to and retained by the Owner, as liquidated damages for such failure or neglect, and to indemnify the Owner for any loss which may be sustained by failure of the Bidder to execute the Contract and furnish documents as aforesaid. In compliance with the Laws of the State the Bidder is: An Individual A Partnership A = roy doy. AiR7 = Via LL 24, ff Soa having principal offices at Aruna, al] DSER, P24

NOTICE OF AWARD Dated: To: (Bidder) ADDRESS. OWNER'S PROJECT NO. PROJECT: OWNER'S CONTRACT NO. CONTRACT FOR You are notified that your Bid dated for the above Contract has been considered. You are the successful bidder and have been awarded a contract for 2025 CDBG ROAD REAHBILITATION The Contract Price of your contractis$ 0. STANDISH AVENUE AND FREMONT STREET Three copies of each of the proposed Contract Documents (except Drawings) accompany this Notice of Award. Drawings will be delivered separately or otherwise made available to you immediately. You must comply with the following conditions precedent within ten days of the date of this Notice of Award, that is by LN You must deliver to the OWNER three (3) fully executed counterparts of the Agreement including all the Contract Documents. 2; You must deliver with the executed Agreement the Contract Security (Bonds) as specified in the Instructions to Bidders (paragraphs 8 and 9), General Conditions (Section 18), and Supplementary Specifications (Section 151). 3. Other conditions: A. Certificates of insurance in not less than the required amounts, types, and form per Paragraph 11 of the Instructions to Bidders. B. Progress schedule per Section 19 of the General Conditions. Failure to comply with these conditions within the time specified will entitle OWNER to consider your bid abandoned, to annul this Notice of Award and to declare your Bid Security forfeited. P-25

Within ten days after you comply with those conditions, OWNER will return to you one fully signed counterpart of the Agreement with the Contract Documents attached. TOWNSHIP OF WEST ORANGE, NEW JERSEY (Owner) Receipt of this "Notice of Award" is acknowledged. Contractor: By: Printed Name Signature Date Title Copy to ENGINEER (Use Certified Mail, Return Receipt Requested) P-26

PERFORMANCE & PAYMENT BOND NOTICE TO PROCEED NEW JERSEY STATUTORY FORM OF PERFORMANCE BOND KNOW ALL MEN BY THESE PRESENTS, that we, the undersigned, as Principal and. as Sureties, are hereby held and firmly bound unto the Township of West Orange in the penal sum of. Dollars, for the payment of which will and truly to be made, we hereby jointly and severally bind ourselves, our heirs, executors, administrators, successors and assigns. Signed this day of 20 The Condition of the above obligation is such that whereas the above named principal did on the day of 20 enter into a contract with Township of West Orange which said contract is made a part of this bond the same as though set forth herein: NOW, if the said principal shall well and faithfully do and perform the things agreed by said principal to be done and performed according to the terms of said Contract, and shall pay all lawful claims of subcontractors, materialmen, laborers, persons, firms or corporations for labor. performed or materials, provisions, provender or other supplies or teams, fuels, oils, implements or machinery furnished, used or consumed in the carrying forward, performing or completing of said contract, we agreeing and assenting that this undertaking shall be for the benefit of any subcontractor, materialman, laborer, person, firm or corporation having a just claim, as well as for the obligee herein; then this obligation shall be void; otherwise the same shall remain in full force and effect; it being expressly understood and agreed that the liability of the surety for any and all claims hereunder shall in no event exceed the penal amount of this obligation as herein stated. The said surety hereby stipulates and agrees that no modifications, omissions or additions in or to the terms of said Contract or in or to the plans and specifications therefore shall in anywise affect the obligation of said surety on its bond. Recovery of any claimant under the bond shall be subject to the conditions and provisions of NUSA 2A:44-143 et. seq., to the same extent as if such conditions and provisions were fully incorporated in the form set forth herein. P-27

IN WITNESS WHEREOF, this instrument is executed in counterparts, each one of which shall be deemed an original, this day of , 20. ATTEST: Principal (Contractor) BY: (S) (Principal) Secretary or Witness as to Principal (Typed Name) (Address) ATTEST: Surety BY:, (S) Attorney-in-Fact (Surety) Secretary (Typed Name) or Witness as to Surety (SEAL) (Address) ‘NOTE: Date of Bond must not be prior to date of Contract. If CONTRACTOR is a Partnership, all partners must execute bond and signature sheets, as necessary. A corporate acknowledgment and statement of authority to be attached by the Surety Company. APPROVAL OF BOND The foregoing Bond approved this day of. , 20. SIGNED BY. SIGNATURE, (S) TITLE. NOTE: The attorney-in-fact signing the Performance Bond on behalf of the surety should attach a valid power of attorney to the Performance Bond. P-28