Fort Walton Beach Council agenda — 02-26-13--regular — reading text

NAME OF U S( ` NESS: Cvvv` C Y\_ ogre Sr_- r rV 1 c- r BY: SIGNATURE 11 NAME & TITLE, TYPED OR PRINTED: p \ 7L y,.va v e. VYt_ Page 9 of 28  6ulpue- I M3 Is poop 6ullslxg Jo luawaoeldoU £ LO-£ L 911 : ZOZZ) auueW web - Ols ELo -£ L quawg3eI1V m° m n a Replacement of Existing Boat Dock at Fed Welton Lording ITBgl3 -011 YU SECTION 2. 6 PUBLIC ENTITY CRIME FORM - RFP 13 -013 a° SWORN STATEMENT UNDER SECTION 287. 133 ( 3) ( A) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted with Proposal, Proposal or Contract # — © \ This sworn statement is submitted by YZ am whose business address is 4"-t( vty e,- Itt ., ae Mp t= t and ( if applicable) Federal Employer Identification Number ( FEIN) ( If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement). My name is ' r V\ t- -( j 2- and my relationship to the entity named above is 1 understand that a " public entity crime" as defined in Paragraph 287. 133( a)( g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any proposal or contract for goods or services to be provided to any public entity or any agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. I understand that " convicted" or " conviction" as defined in paragraph 287. 133( a)( b), Florida Statutes, means finding of guilt or a conviction of a public entity crime with or without an adjudication of guilt, in any federal or state trial court of records relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non -jury trial, or entry of plea of guilty or nolo contendere. I understand that an " affiliate" as defined in Paragraph 287. 133( 1)( a), Florida Statutes, means: A predecessor or successor of a person convicted of a public entity crime (or) An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term " affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one of shares constituting a controlling income among persons when not for fair interest in another person, or a pooling of equipment or income among persons when not for fair market value under a length agreement, shall be a prima facie case that one person controls another person. A person who was knowingly convicted of a public entity crime, in Florida during the preceding 36 months shall be considered an affiliate. I understand that a " person" as defined in Paragraph 287. 133( l )( a), Florida Statutes, means any natural person or entity organized under the laws of the state or of the United States with the  Buipue I Md le Nee(] Suilsix3 Jo fuawaoeldaa £ LO -£ L 911 : ZOZZ) atu eW web - Ols £ LO-£ L quawgoellV u w Hv am Replazemenl of Existing Scat DOCA at Fort Welton Landing IT6 # 13 - 013 YaU legal power to enter into a binding contract for provision of goods or services let by a public a entity, or which otherwise transacts or applies to transact business with a public entity. The term person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. ( Please indicate which statement applies.) Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, nor affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. ( Please attach a copy of the final order.) The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing ofliicer determined that it was in public interest to remove the person or affiliate from the convicted vendor list. ( please attach a copy of the final order) The person or affiliate has not been placed on the convicted vendor list. ( Please describe any action taken by, or pending with, the Department of General Services Signature) ( Sig 1! Date) T STATE OF: COUNTY OF: PERSONALLY APPEARED BEFORE, ME, the undersigned authority, who, after first being sworn by me, affixed his /her signature at the space provided N this (` day of c_ t - 2013, and is rsonally known m m or has provided_ as identification. Notar4ublic My Commission expires d 4 ed i { eN11 lb.EE 217c3s apnMlNebn lbW7IWIO• Flmide eL1onO } 7 } 1! Page I l of 28  Bulpue- 1 Mj 3e MDop Bupslx3 ; o 7uawaoeldoN £ 90-£ 2- 811 : ZDZZ) euueW wea - (718 £ 60-£ 2- auowyoelly 04 H- CORD CERTIFICATE OF LIABILITY INSURANCE raoeecm onmlxvmnmra 07M= 2 THIS CERTIFICATE IS ISSUED pg A MATTFA OF WFORMATION a Y Dealer Risk Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTItTCATE a A 1101 N. CongreseAm SIR. # 201 HOLDER THIS CERTIFICATE DOES NOT AMEND E%TEND OR Boynton Beach, FL 77426 ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW. PhoRn8561752 -0199Fax 561752-3039 INSURERSAFFORDINGCOVERAGE NAN:# RR RA Sealer htlneuraace Co Ram Marine Inc. a Ru. AUMndc Wei Inmam CO 494 RNarviewOrNe Nokomis, FL 34275 - NeU FRo COVERAGES  Bu! pue- 1 Mj le 1000 Bupslx3 ; o luawsoeldab £ LO-£ I. 811: ZOZZ) auliepy web - OIS £ LO -EL quawyoelTv DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION am 850) 487 - 1395 CONSTRUCTION INDUSTRY LICENSING BOARD ( x 1940 NORTH MONROE STREET u a, „.` TALLAHASSEE FL 32399 - 0783 a LOWELL, DAVID ANDREW RAM MARINE SERVICES, INC 494 RIVERVIEW DR