Kernersville B-40 & South - Town of Kernersville

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Contract No._11509 (WBS #: 3709.3.23; TIP #: ER-2973 I) County: __Forsyth____________________ EXECUTION OF BID NON-COLLUSION AFFIDAVIT, DEBARMENT CERTIFICATION AND GIFT BAN CERTIFICATION JOINT VENTURE (2) or (3) Rev.4-19-11 The person executing the bid, on behalf of the Bidder, being duly sworn, solemnly swears (or affirms) that neither he, nor any official, agent or employee of the bidder has entered into any agreement, participated in any collusion, or otherwise taken any action which is in restraint of free competitive bidding in connection with any bid or contract, that the bidder has not been convicted of violating N.C.G.S. § 133-24 within the last three years, and that the Bidder intends to do the work with its own bonafide employees or subcontractors and is not bidding for the benefit of another contractor. In addition, execution of this bid in the proper manner also constitutes the Bidder's certification of status under penalty of perjury under the laws of the United States in accordance with the Debarment Certification attached, provided that the Debarment Certification also includes any required statements concerning exceptions that are applicable. N.C.G.S. § 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any State Employee of any gift from anyone with a contract with the State, or from any person seeking to do business with the State. By execution of any response in this procurement, you attest, for your entire organization and its employees or agents, that you are not aware that any such gift has been offered, accepted, or promised by any employees of your organization. SIGNATURE OF CONTRACTOR Instructions: 2 Joint Venturers Fill in lines (1), (2) and (3) and execute. 3 Joint Venturers Fill in lines (1), (2), (3) and (4) and execute. On Line (1), fill in the name of the Joint Venture Company. On Line (2), fill in the name of one of the joint venturers and execute below in the appropriate manner. On Line (3), print or type the name of the other joint venturer and execute below in the appropriate manner. On Line (4), fill in the name of the third joint venturer, if applicable and execute below in the appropriate manner. (1) ______________________________________________________________________________________________________ Name of Joint Venture (2) ______________________________________________________________________________________________________ Name of Contractor ______________________________________________________________________________________________________ Address as Prequalified _______________________________________ ___________________________________________ Signature of Witness or Attest By Signature of Contractor _______________________________________ Print or type Signer's name ___________________________________________ Print or type Signer's name If Corporation, affix Corporate Seal and (3) _____________________________________________________________________________________________________ Name of Contractor _____________________________________________________________________________________________________ Address as Prequalified _______________________________________ _________________________________________ Signature of Witness or Attest By Signature of Contractor _______________________________________ _________________________________________ Print or type Signer's name Print or type Signer's name If Corporation, affix Corporate Seal and (4) _____________________________________________________________________________________________________ Name of Contractor (for 3 Joint Venture only) _____________________________________________________________________________________________________ Address as Prequalified ________________________________________ _________________________________________ Signature of Witness or Attest By Signature of Contractor ________________________________________ _________________________________________ Print or type Signer's name Print or type Signer's name 11509; WBS #: 3709.3.23 B40 Interchange Landscape (Forsyth County) 74
Contract No._11509 (WBS #: 3709.3.23; TIP #: ER-2973 I) County: __Forsyth____________________ Rev.4-19-11 If Corporation, affix Corporate Seal NOTARY SEAL NOTARY SEAL NOTARY SEAL Affidavit must be notarized for Line (2) Affidavit must be notarized for Line (3) Affidavit must be notarized for Line (4) Subscribed and sworn to before me this Subscribed and sworn to before me this Subscribed and sworn to before me this ______day of ______________20______ day of 20_______ ______day of _______ 20_____ Signature of Notary Public Signature of Notary Public Signature of Notary Public _______________________________ ____ ___________________________ ________ ____________________________________ of _________ County of __________ County of _________ County State of _____________________________ State of _____________________________ State of _____________________________ My Commission Expires:_____________ My Commission Expires:___________ My Commission Expires: _______________ 11509; WBS #: 3709.3.23 B40 Interchange Landscape (Forsyth County) 75
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TOWN OF KERNERSVILLE COMMUNITY DEVE
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PROJECT SPECIAL PROVISIONS - LANDSC
Page 5 and 6:
PROPOSAL FOR THE CONSTRUCTION OF KE
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NCDOT STANDARD NOTES (FEDERAL AID)
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PROJECT STANDARD SPECIAL PROVISIONS
Page 11 and 12:
Liquidated damages chargeable due t
Page 13 and 14:
Subcontractor Quote Comparison Shee
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One complete set and 4 copies of th
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(A) Participation The total dollar
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during the term of the lease with t
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subcontractor). This accounting sha
Page 23 and 24: By Executive Order 24, issued by Go
Page 25 and 26: (b) (c) (d) (e) (f) (g) (h) (i) Ins
Page 27 and 28: Revocation or Suspension of Certifi
Page 29 and 30: standard compensatory BMPs. Other T
Page 31 and 32: Division 4 Page 4-77, line 27, Suba
Page 33 and 34: geographical area located outside o
Page 35 and 36: Form FHWA-1273 must be included in
Page 37 and 38: (1) The number and work hours of mi
Page 39 and 40: Apprenticeship Training, Employer a
Page 41 and 42: In order to assure high quality and
Page 43 and 44: 1. The prospective participant cert
Page 45 and 46: Trainee Wages Contractors shall com
Page 47 and 48: Alamance County 14.83 Davie, Forsyt
Page 49 and 50: Administrative Review Board U.S. De
Page 51 and 52: COMPENSATION: All work or items, ot
Page 53 and 54: D. CONTRACTOR'S WARRANTY OF TITLE:
Page 55 and 56: the unpaid balance of the Contract
Page 57 and 58: mulch, and any other materials; pru
Page 59 and 60: delivered to North Carolina Departm
Page 61 and 62: Stabilization Requirements: (11-4-1
Page 63 and 64: Install Work Zone Advance Warning S
Page 65 and 66: When resurfacing facilities with ra
Page 67 and 68: Measurement and Payment Payment wil
Page 69 and 70: Contact Person:____________________
Page 71 and 72: Contract No._11509 (WBS #: 3709.3.2
Page 73: Contract No._11509 (WBS #: 3709.3.2
Page 81 and 82: Contract No._11509 (ER-293 I)______
Page 87 and 88: Contract # 11509; WBS #: 3709.3.23
Page 89 and 90: BID FORM KERNERSVILLE B-40 & SOUTH
Page 91: LETTER OF INTENT TO PERFORM AS A SU
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Kernersville B-40 & South - Town of Kernersville

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