Okaloosa County BOCC — April 5, 2016 — Palm Beach Bid 15-063-LC — reading text

non-discrimination policy in conformance with Palm Beach County’s policy set forth above; or (ii) provide Palm Beach County with the information set forth above, will render bidder non-responsive. Bidder shall notify Palm Beach County in the event it no longer maintains a written or non-written non- discrimination policy that is in conformance with Palm Beach County’s policy set forth above. Failure to maintain said non-discrimination policy shall be considered a default of contract. BIDDER: Company Name Signature Name (type or print) Title Rev. 01.16.15  Page 16 SCHEDULE 1 LIST OF PROPOSED SBE-M/WBE PRIME AND/OR SUBCONTRACTOR PARTICIPATION PROJECT NAME OR BID NAME:_______________________________________ PROJECT NO. OR BID NO.: ___________________________________________ NAME OF PRIME BIDDER:____________________________________________ ADDRESS: ______________________________________________________________ CONTACT PERSON:__________________________________________________ PHONE NO.: _________________________FAX NO.:_____________________________ BID OPENING DATE:__________________________________________________ USER DEPARTMENT: ______________________________________________________ THIS DOCUMENT IS TO BE COMPLETED BY THE PRIME CONTRACTOR AND SUBMITTED WITH BID PACKET. PLEASE LIST THE NAME, CONTACT INFORMATION AND DOLLAR AMOUNT AND/OR PERCENTAGE OF WORK TO BE COMPLETED BY ALL SBE -M/WBE SUBCONTRACTORS ON THIS PROJECT. IF THE PRIME IS AN SBE-M/WBE, PLEASE ALSO LIST THE NAME, CONTACT INFORMATION AND DOLLAR AMOUNT AND/OR PERCENTAGE OF WORK TO BE COMPLETED BY THE PRIME ON THIS PROJECT. THE PRIME AFFIRMS THAT IT WILL MONITOR THE SBES LISTED TO ENSURE THE SBES PERFORM THE WORK WITH ITS OWN FORCES. (Check one or both Categories) M/WBE SBE DOLLAR AMOUNT OR PERCENTAGE OF WORK Name, Address and Phone Number Minority Small Black Hispanic Women Caucasian Other (Please Business Business Specify) _________ __________ __________ __________ __________ 1. _________ _________ __________ _________ __________ 2. _________ _________ __________ _________ _________ 3. __________ __________ __________ __________ ________ 4. _________ _________ __________ __________ _________ 5. (Please use additional sheets if necessary) Total __________ ___________ ___________ ___________ _________ Total Bid Price $ ________________________________________ Total SBE-M/WBE Participation Dollar Amount or Percentage of Work _____ ______________________ I hereby certify that the above information is accurate to the best of my knowledge:________________________________________________________________________________________________________ Signature Title Note: 1.The amount listed on this form for a subcontractor must be supported by price or percentage listed on the signed Schedule 2 or signed proposal in order to be counted toward goal attainment. 2. Firms may be certified by Palm Beach County as an SBE and/or an M/WBE. If firms are certified as both an SBE and M/WBE, please indicate the dollar amount and/or percentage under the appropriate category. 3. M/WBE information is being collected for tracking purposes only. Revised 9/7/2011  Page 17 OSBA SCHEDULE 2 LETTER OF INTENT TO PERFORM AS AN SBE-M/WBE SUBCONTRACTOR This document must be completed by the SBE-M/WBE Subcontractor and submitted with bid packet. Specify in detail, the particular work items to be performed and the dollar amount and/or percentage for each work item. SBE credit will only be given for items which the SBE-M/WBE Subcontractor are SBE certified to perform. Failure to properly complete Schedule 2 may result in your SBE participation not being counted. PROJECT NUMBER: _____________________________ PROJECT NAME: ___________________________________ TO: ________________________________________________________________________________________________ (Name of Prime Bidder) The undersigned is certified by Palm Beach County as a - (check one or more, as applicable): Small Business Enterprise _____ Minority Business Enterprise _____ Black _____ Hispanic _____ Women _____ Caucasian _____ Other (Please Specify) ______________ Date of Palm Beach County Certification: _____________________________________ The undersigned is prepared to perform the following described work in connection with the above project. Additional Sheets May Be Used As Necessary Line Item/ Total Price/ Lot No. Item Description Qty/Units Unit Price Percentage ____ _______________________________________ _________ _________ __________ ____ _______________________________________ _________ _________ __________ ____ _______________________________________ _________ _________ __________ ____ _______________________________________ _________ _________ __________ ____ ____________________________________ ___ _________ _________ __________ ____ ____________________________________ ___ _________ _________ __________ at the following price or percentage ___________________________________________________________________________________________________________ (Subcontractor’s quote) and will enter into a formal agreement for work with you conditioned upon your execution of a contract with Palm Beach County. If undersigned intends to subcontract any portion of this job to a certified SBE or a non-SBE subcontractor, please list the name of the subcontractor and the amount below. Price or Percentage ______________________________/ ____________________________________________________ (Name of Subcontractor) The Prime affirms that it will monitor the SBE’s listed to ensure the SBE’s perform the work with its own forces. The undersigned subcontractor affirms that it has the resources necessary to perform the work listed without subcontracting to non-certified SBE or any other certified SBE subcontractors except as noted above. The undersigned subcontractor understands that the provision of this form to Prime Bidder does not prevent Subcontractor from providing quotations to other bidders. ___________________________________________________ (Print name of SBE-M/WBE Subcontractor) By: ________________________________________________ (Signature) ___________________________________________________ (Print name/title of person executing on behalf of SBE/M/WBE Subcontractor Revised 10/11/2011 Date: __________________________________________  Page 18 OSBA SCHEDULE 3 SBE-M/WBE ACTIVITY FORM SBE-M/WBE ACTIVITY FOR MONTH ENDING_________________________ PROJECT#:________________________________________ PROJECT NAME____________________________________________________________________________________________________ PRIME CONTRACTOR NAME__________________________________________________________________________________________ PROJECT SUPERVISOR______________________________________________________________________________________________ Schedule 3 is used to show the monthly payment activity for work performed by each SBE-M/WBE Subcontractor on the project and in conformity with the SBE-M/WBE’s submitted on schedule 2. It also shows approved change orders as they impact the SBE-M/WBE Subcontractors. Schedule 3 is to be submitted by the Prime with each payment request to Palm Beach County. In the SBE-M/WBE Subcontracting Information section, list the name(s) of each SBE-M/WBE Subcontractor on the project and the total contracted amount for each SBE-M/WBE Subcontractor on the project. As the project proceeds, please complete each column under the SBE-M/WBE Subcontracting Information section accordingly. In the SBE-M/WBE Category, please check the appropriate category that represents each SBE-M/WBE Subcontractor. SBE-M/WBE SUBCONTRACTING INFORMATION SBE-M/WBE Category (check all applicable) Name of SBE- SBE- Approved Revised Amount drawn Amount Amount Paid to Actual Minority Small