HomeMy Public PortalAbout2020.10.08 Falvey Construction Contract Brown ParkTHIS AGREEMENT, is being made and entered into this A day of -e-20 200and between The Cit
of McCall (hereinafter, "OWNER") and I e ° t L (hereinafter,
"CONTRACTOR"):
NOW THEREFORE, the parties to this Contract, in consideration of the mutual covenants and stipulations
set out, agree as follows:
,ARTICLE 1. "CONTRACT DOCUMENTS
The Contract Documents which comprise the entire agreement betweenthe OWNER or City and the
Contractor concerning the ' cork to be performed are this Contract as defined by the following:
. Rid Documents titled, BROWN PARK SLOPE STABILIZATION IMPROVEMENTS
2. Standard general Conditions of the Construction Contract, 2017 ISPWC (Idaho Standards for Public
Works Construction) Division 100 (not attached) (pages 1 to 52, inclusive).
3. Rid Proposal (Section ) of the Contractor, dated 2020 to be physically
attached to this Contract;
. The Construction Plans (6 sheets;
S. Agreement (Section )
. General Conditions (Section S)
7. Supplementary Conditions (Section
8. Technical Specifications (Section 7)
9. Special Provisions (Section R)
10. Performance and Payment Bonds and Insurance Certificates, to be physically attached to this
Contract
1. The following which may be delivered or issued on or after the Effective Date of the Agreement and
are not attached hereto:
a. Notice of Award
b. Notice to Proceed.
c. Written Amendments.
da Work Change Directives.
. Change Orders,
f. Substantial completion certification
g. Final completion certification
. Addenda issued prior to opening of bids.
13. - Public Works Contract Report for Idaho State Tax Commission
a
This Contract may only be amended by change order as provided in the General Conditions.
ARTICLE 2. WORK
The Contractor shall complete the entire work as specified, indicated and required under the Contract
Documents. The Work is generally described as follows: BROWN PARK SLOPE STABILIZATION
IMPROVEMENTS.
ARTICLE 3. PROJECT MANAGER and PROJECT ENGINEER
3.01 The City of McCall Parks & Recreation Director (Project Manager), is to act as the OWNER's
representative and assume all duties and responsibilities, and have the rights and authority
assigned to "OWNER" in the Contract Documents in connection with the completion of the
"Work" in accordance with the Contract Documents and the General Conditions of the Idaho
Standards for Public Works Construction (ISPWC).
3.02 The project has been designed by Horrocks Engineers and the project will be inspected by the
City of McCall, which is to act as the OWNER's representative, assume all duties and
responsibilities, and have the rights and authority assigned to "Engineer" in the Contract
Documents in connection with the completion of the "Work" in accordance with the Contract
Documents and the General Conditions of the Idaho Standards for Public Works Construction
(ISPWC).
ARTICLE 4. CONTRACT TIMES/LIMITATIONS
4.01 Milestones
Completion of the slope stabilization by November 20", 2020.
4.02 Substantial Completion
The Contractor shall begin work in conformance with the Contract Documents and shall complete
the work prior to the date of completion. The project site will be available to the Contractor for
project implementation on or around October 12, 2020 or when weather conditions permit, and
only after approval of the Project Engineer. The work to be performed pursuant to this Contract
shall be substantially complete within 30 working days after Notice to Proceed.
The project will be considered "Substantially Complete" when all the slope stabilization
improvements are complete, and the shoreline is open for public use.
4.03 Final Completion
The work shall be finally complete and ready for final payment, in accordance with Paragraph 14.07
of the ISPWC General Conditions, within 10 working days of the date of Substantial Completion
Certification.
21
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS
4.04 Working Hours
Work can be performed 5 days a week (Monday through Friday) for a period of 12 hours (7:00 am
to 7:00 PM) per day. Adjustment of the contract time can be made in accordance with the
provisions of the Contract Documents as directed by the Project Engineer, Public Works Director, or
the OWNER. Requests to perform work outside of these hours should be submitted to the Resident
Project Representative, for approval, at least 3 days in advance.
4.05 Liquidated Damages
A. CONTRACTOR and OWNER recognize that time is of the essence of this Agreement and that OWNER
will suffer financial loss if the Work is not completed within the times specified in paragraphs 4.01 and
4.02 above, plus any extensions thereof allowed in accordance with Article 12 of the ISPWC Section
100 General Conditions. The parties also recognize the delays, expense, and difficulties involved in
proving in a legal preceding the actual loss suffered by OWNER if the Work is not completed on time.
Accordingly, instead of requiring any such proof, OWNER and CONTRACTOR agree that as liquidated
damages for delay (but not as a penalty), CONTRACTOR shall pay OWNER $1200.00 for each day that
expires after the time specified in paragraph 4.02 for Substantial Completion until the Work is
substantially complete and in paragraph 4.03 for Final Completion until the Work has been approved
as complete by the Engineer.
ARTICLE S. CONTRACT PRICE
OWNER shall pay CONTRACTOR for completion of the Work in accordance with the Contract Documents the
amount Of Three Hundred Eighty Six Thousand & One Hundred Twenty Five ($ 386,125.00) in current funds equal to the sum
of the amounts determined pursuant to the CONTRACTOR's Bid Proposal contained in Bid Form, Article 5,
Section III.
ARTICLE 6 - PAYMENT PROCEDURES
6.01 Submittal and Processing of Payments
A. CONTRACTOR shall submit Applications for Payment in accordance with Article 14 of the General
Conditions. Applications for Payment will be processed by ENGINEER as provided in the General
Conditions. Contractor shall provide an example Application for Payment submittal to the Project
Engineer at the start of the project for review and approval.
6.02 Progress Payments; Retainage
A. OWNER shall make progress payments on account of the Contract Price on the basis of
CONTRACTOR's Applications for Payment on or about the 30th day of each month during performance
of the Work as provided in paragraphs 6.02.A.1 and 6.02.A.2 below. All such payments will be
measured by the schedule of values established in paragraph 2.07.A of the General Conditions (and in
the case of Unit Price Work based on the number of units completed) or, in the event there is no
schedule of values, as provided in the General Requirements:
1. Prior to Substantial Completion, progress payments will be made in an amount equal to the
percentage indicated below but, in each case, less the aggregate of payments previously
22
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS
made and less such amounts as ENGINEER may determine or OWNER may withhold, in
accordance with paragraph 14.02 of the General Conditions:
a. 95% of Work completed (with the balance being retainage): and
b. 95% of cost of materials and equipment not incorporated in the Work (with the balance
being retainage).
2. Upon Substantial Completion, Owner shall pay an amount sufficient to increase total
payments to Contractor to 95 percent of the Work completed, less such amounts as
ENGINEER shall determine in accordance with Paragraph 14.02.8.5.
6.03 Final Payment
A. Upon final completion and acceptance of the Work in accordance with paragraph 14.07 of the General
Conditions, OWNER shall pay the remainder of the Contract Price as recommended by ENGINEER as
provided in said paragraph 14.07, less any sum Owner is entitled to set off against Engineer's
recommendation, including but not limited to liquidated damages.
ARTICLE 7 - INTEREST
7.01 All moneys not paid when due as provided in Article 14 of the General Conditions shall bear interest
at the rate of 5% per annum.
ARTICLE 8. INDEPENDENT CONTRACTOR
The parties warrant by their signature that no employer -employee relationship is established between the
Contractor and the OWNER by the terms of this contract. It is understood by the parties hereto that the
Contractor is an independent contractor and as such neither it nor its employees, agents, representatives
or subcontractors, if any, are employees of the OWNER for purposes of tax, retirement system, or social
security (FICA) withholding.
ARTICLE 9. SCOPE OF SERVICES
The Contractor shall perform all services required by the Contract Documents. All work shall be completed
in accordance with the specifications and plans established for this project.
ARTICLE 10. HOLD HARMLESS/INDEMNIFICATION
In addition to other rights granted the OWNER by the Contract Documents, the Contractor shall indemnify
and save harmless the Engineer and the Owner, its officers and employees, from all suits, actions, or claims
of any character brought because of any injuries or damages received or sustained by any person, persons,
or property on account of the operations of the Contractor or his subcontractors; or on account of or in
consequence of any neglect in safeguarding the work; or through use of unacceptable materials in
constructing the work; or because of any act or omission, neglect, or misconduct of the Contractor or his
subcontractors; or because of any claims or amounts recovered from any infringements of patent,
trademark or copyright; or from any claims or amounts arising or recovered under the Workmen's
Compensation Act or any other law, ordinance, order or decree.
23
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS
ARTICLE 11. CONFLICT OF INTEREST
The Contractor covenants that it presently has no interest and will not acquire any interest, direct or
indirect, in the project which would conflict in any manner or degree with the performance of its services
hereunder. The Contractor further covenants that, in performing this Contract, it will employ no person
who has any such interest. Should any conflict of interest arise during the performance of this Contract,
Contractor shall immediately disclose such conflict to the Project Manager, and the OWNER.
ARTICLE 12. ENTIRE AGREEMENT, MODIFICATION AND ASSIGNABILITY
This Contract and the exhibits hereto contain the entire agreement between the parties, and no statements,
promises, or inducements made by either party, or agents of either party are valid or binding unless
contained herein. This contract may not be enlarged, modified or altered except upon written agreement
signed by the parties hereto. The Contractor may not subcontract or assign its rights (including the right to
compensation) or duties arising hereunder other than as contemplated by the Contract Documents, without
the prior written consent and express authorization of the OWNER.
ARTICLE 13. ADHERENCE TO LAW REQUIRED
All applicable local, state and federal statutes and regulations are hereby made a part of this contract and
shall be adhered to at all times. Violation of any,of'fHie5L'statutes or regulations by the Contractor shall be
deemed material and shall subject the Contract& tp.tgijnation of this contract for cause. No pleas of
misunderstanding or ignorance on the part oftht+Contractor will in any way serve to modify the provisions
of this requirement. The Contractor anAiS surety slW%ndemnify and save harmless the OWNER and the
City of McCall and its employees, age nt!F,.aad:rep&to4ives against any claim or liability arising from or
based on the violation of any such laws;."c'pdes,dMiinances, or regulations, whether by himself, his
employees, or his subcontractors. %��
ARTICLE 14. LEGAL FEES
In the event either party incurs legal expenses to enforce the terms and conditions of this contract, the
prevailing party is entitled to recover reasonable attorney's fees and other costs and expenses, whether the
same are incurred with or without suit.
ARTICLE 15. SPECIAL WARRANTY
The Contractor warrants that nothing of monetary value has been given, promised or implied as
remuneration or inducement to enter into this Contract. The Contractor further declares that no improper
personal, political or social activities have been used or attempted in an effort to influence the outcome of
the competition, discussion, or negotiation leading to the award of this Contract. Any such activity by the
Contractor shall make this Contract null and void.
24
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS
ARTICLE 16. COMMUNICATIONS
Such communications as are required by this contract shall be satisfied by mailing or by personal delivery
to the parties at the following address:
Contractor: Falvey's LLC
P.O. Box 710
McCall, ID 83638
Owner: City of McCall
216 E. Park Street
McCall, Idaho 83638
IN WITNESS WHEREOF, said Contractor and the OWNER or City has caused this Contract to be executed on
the day and year first above written.
Contractor- Owner:
by: Mathew Falvey, Owner 40 I
ON Robert S.z4wMayor
or. X,
.§ 4
S
CT:�
-4-
sieJo Walfber, City Cie
Approved As To Form:
William F. Nichols, City Attorney
ACKNOWLEDGMENT
On this day of 2020, before me, a Notary Public of the State of
Idaho, personally appeared in his/her official capacity as
known to me to be the person described in the above document and
acknowledged to me he/she executed the same.
SEAL Notary Public restding at
My COMmission expires
25
BROWN PARK SLOPE &rABILIZATION IMPROVEMENTS
ARTICLE 16. COMMUNICATIONS
Such communications as are required by this contract shall be satisfied by mailing or by personal delivery
to the parties at the following address:
Contractor: Falvey's LLC
P.O. Box 710
McCall, ID 83638
Owner: City of McCall
216 E. Park Street
McCall, Idaho 83638
IN WITNESS WHEREOF, said Contractor and the OWNER or City has caused this Contract to be executed on
the day and year first above written.
Contractor: Owner:
by: Mathew Falvey, Owner �*�����i,,Robert S. , Mayor
-�' �AT ST: %
Iw
s
l
$3sieJo Walfher, City Cle
Approved As T
William F. Nichols, City Attorney
ACKNOWLEDGMENT
On this day of 2020, before me, a Notary Public of the State of
Idaho, personally appeared I in his/her official capacity as
, known to me to be the person described in the above document and
acknowledged to me he/she executed the same.
SEAL Notary Public residing at
My Commission expires
25
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS
THIS PAGE LEFT BLANK INTENTIONALLY FOR DOUBLE SIDED
COPYING.
26
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS
3 BIDDERS PROPOSAL
ARTICLE 1— BID RECIPIENT
1.01 This Bid is submitted to the City of McCall. This bid is for the Project titled: BROWN PARK SLOPE
STABILIZATION IMPROVEMENTS
ARTICLE 2 — BIDDER'S INFORMATION
2.01 BIDDER's Name: rQ 1 v
BIDDER'S Idaho Public Works Contractor License No.: Pwd -C—I 1p�l (p— -A 4
License Expiration Date: .4 —U—'-J I
BIDDER's Business Address: P6. 3°y, -71 D fthe-&a{r (y e3039
BIDDER's Business Phone No.:_ 0f-fQ-j4—'?VoZ
BIDDER'S FAX No.:k)JA
BIDDER'S Email Address:
ARTICLE 3 — BIDDER'S ACKNOWLEDGEMENTS
This proposal is submitted as an offer by the undersigned to enter into contract with the City of McCall,
McCall Idaho, hereinafter referred to as the "OWNER" for the BROWN PARK SLOPE STABILIZATION
IMPROVEMENTS project, specified herein, and which construction documents are on file with the Public
Works Department, 815 N. Samson Trail, McCall, Idaho, and which are a condition hereof with the same
force and effect as though they were attached hereto. The offer is conditioned on the following
declarations as to the facts, intention and understanding of the undersigned and the agreement of the
OWNER to the terms and prices herein submitted.
1. All project specifications and drawings have been examined by the undersigned and their terms
and conditions are hereby agreed to.
The undersigned certifies that he/she has received or made himself/herself aware of any and all
existing site conditions that may affect the proposed work.
It is understood that the contract drawings may be supplemented by additional drawings and
specifications in explanation and elaboration of the contract drawings and it is agreed that such
supplemental drawings, when not in conflict with those referred to in paragraph 1 above, will
have the same force and effect as if attached hereto and that when received they will be
considered a part of the contract.
4. The undersigned will furnish separate performance and payment bonds and insurance
certificates, as required by the specifications, in the full amount of the contract price within the
BROWN PARR SLOPE STABILIZATION IMPRO\ EMENTS
time limit therein after notification that the said proposal is accepted, all in accordance with the
provisions of this proposal and the specifications.
6. The undersigned further agrees that the OWNER shall have the right to accept or reject any bid
as the OWNER deems to be in their best interest.
7. The undersigned agrees to order all necessary equipment and materials within a period of three
(3) days after Notice to Proceed has been issued by the OWNER.
8. The undersigned, as a BIDDER, acknowledges that Addenda Number through
have been delivered to him/her and have been examined as part of the contract
documents.
The undersigned agrees to complete all work embraced in the contract within the time limitations
set forth in paragraph IB-10 of the Instruction to Bidders.
10. Bidder acknowledges that estimated quantities are not guaranteed, and are solely for the purpose
of comparison of bids. The city has a set budget for this project that cannot be exceeded. Once
bids are opened and the apparent low bidder is identified, the City reserves the right to eliminate
or reduce any items they deem necessary to stay within budget. There will be no compensation
to the Contractor for the elimination of items of work. The Contractor is advised to provide
balanced bids for all items of work.
ARTICLE 4 — BIDDERS'S CERTIFICATION
4.01 BIDDER certifies that:
A. This Bid is genuine and not made in the interest of or on behalf of any undisclosed
individual or entity and is not submitted in conformity with any collusive agreement or rules of
any group, association, organization, or corporation; BIDDER has not directly or indirectly induced
or solicited any other BIDDER to submit a false or sham Bid; and BIDDER has not sought by
collusion to obtain for itself any advantage over any other BIDDER or over OWNER.
ARTICLE S — BASIS OF BID/BID SCHEDULE
5.01 BIDDER will complete the Work in accordance with the Contract Documents for the following
price(s):
Bid Item
Item Description
Spec Reference
Quantity
Unit
Unit
Price
Total
Amount
1
Removal of Obstructions
201.4.1.C.1
1
LS
2000•00
; OOO. 00
2
Removal of Rock
201.4.1.D.1
400
SY
40,00
14006.00
3
Removal of Landscaping
201.4.1.D.2
250
SY
1 Z, 0,0
3000.00
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS 9
Bid Item
Item Description
Spec Reference
Quantity
Unit
Unit
Price
Total
Amount
4
Removal of Gravel
201.4.1.D.3
1100
SY
4t O0
! .q 00.00
5
Removal of Asphalt
201.4.1.D.4
200
SY
Z0.00
4.0 p0. O0
6
Removal of Pipe
201.4.1.G.1
50
LF
10.00
00
7
Excavation
202.4.1.A.1
1800
CY
2S, a d
f t' f o w
8
Unsuitable Material
Excavation
202.4.5.A.1
SO
CY
f0,¢0560,0
1.
9
Dust Abatement Water
202.4.8.A.1
200
MG
, .00
- 00.00
10
Loose Riprap Dso=15"
206.4.1.H.3A
700
CY
Q46W,06
11
Loose Riprap D50=15"
206.4.1.H.3B
300
CY
to(91-00
3Itgao.06
12
Stabilized Construction
1001.4.2.6.1
1
EA
00
�,t?O 0- 00
Entrance
13
Silt Fence
1003.4.1.C.1
510
LF
3.00
��j 0.00
14
Fiber/Straw Wattles
1003.4.1.G.1
510
LF
.4, 00
Q per. 00
1s
Traffic Control
Barricades, Type ID[)
1103.4.1.C.1
2
EA
Do
F, p pt?- D D
16
Traffic Control
Barricades, Type III'
1103.4.1.C.2
2
EA
00.00
1,000 c�
17
Traffic Control
1103.4.1.).1
6
MH
I ��' 0 0
Maintenance
18
Riprap/Erosion Control
2050.4.1.B.1
2000
SY
�i, DO
jQ000
Geotextile
19
Small Boulders - 30" -
SP-lA
100
CY
rJtoo .O
BROWN PART. SLOPE STABILIZATION IMPROVEMENTS 10
Bid Item
Item Description
Spec Reference
Quantity
Unit
Unit
Price
Total
Amount
20
36m�all Boulders - 30" -
SP-1B
200
CY
�•d O
I �� ADO UD
21
Medium Boulders - 36" -
SP-2A
100
CY
�j5.00
�500.00
48„
22
Medium Boulders - 36" -
SP-26
400
CY
IO15oU
�,� 000
OV
23
LLa0rge Boulders - 48" -
SP-3A
200
CY
24
Large Boulders - 48" -
SP-3B
550
CY
17.0.00
60
25
Landscape Repair
SP-4
1100
SY
i0 •oo
11000. 00
26
Decomposed Granite
SP-5
200
SY
Ejj-DO
J a J ODD. cc
Pathwa Y
27
Surveying
SP-6
1
LS
46,00,
ZSoO.OZ)
Directed Survey
28
(Contingency
SP-7
1
CA
S000
5000.0D
Allowance)
29
Temporary Fencing
SP-8A
150
LF
6.06
7 6 O , O O
(Chain Unk)
30
Temporary Fencing
SP-86
500
LF
3. 00
1, 500.0�
(Oranee Construction)
31
Turbidity Curtain
SP-9
600
LF
2-0•00
IZ000.0D
32
Planting Soil
SP-10
100
Cy
2�•00
4500.0z)
33
Mobilization
2010.4.1.A.1
1
LS
4400 xa
g000•a0
r
BID (Sum of Items 1 through 33) TOTAL (Amount) =
55 600.Qz)
/
BID TOTAL (Words): �� � �• % �' �!�
BROWN PARE: SLOPE STABILIZATION IMPRO\ EMENTS
5.02 BIDDER will complete the Bid Alternate #1 Work in accordance with the Contract Documents for
the following price(s):
Bid Rem
hem Description
Spec Reference
Quantity
Unit
Unit Price
Total
amount
1
Medium Boulders 36" —
48"
SP-213
60
CY
.ZOO.00�
/ �• .AD
2
Large Boulders 48" —
60
SP-3B
60
CY
Ad0.00
l Zf CaG1G.A7
3
Reduction in Loose
2010.4.1.A.1
70
CY
_75•o0
— 5 z Saco
Riprap Dso = 15"
BID (Sum of Items 1 through 3) TOTAL (Amount) =
1 "1 6 0 _V 0
Alt #1 BID TOTAL (Words):
5.02 BIDDER will complete the Bid Alternate #2 Work in accordance with the Contract Documents for
the following price(s):
Reim
Rem Description
Spec Reference
Quantity
Unit
Unit Price
Total
Amount
1
Medium Boulders 36"—
48"
SP-2B
30
CY
,ZDO.O D
t. , wo • co
2
Large Boulders 48" —
SP-313
30
CY
di QQ •D0
QDD ,U
60„
3
Reduction in Loose
2010.4.1.A.1
35
CY
....� Jr• GO
—Zfv • O
Riprap Dso = 15"
BID (Sum of Items 1 through 3) TOTAL (Amount)
Alt #2 BID TOTAL (Words)�—n4 "OaAa 1 Mom'
BROWN PART: SLOPE STABILIZATION IMPRO\ EMENTS 12
ARTICLE 6 — BID SUBMITTAL
6.01 Submitted on "k . 20a0
6.02 This Bid is submitted by:
An Individual
Name (typed or printed):
By:
(individual's signature)
Doing Business As:
A Partnership
Partnership Name:
By:
(Signature of general partner— attach evidence of authority to sign)
Name (typed or printed):
A Corporation
Corporation Name: Fe, IV[-Ld
State of Incorporation: I efo-� O
Type (General Businvs, Professional, Service, Limited Liability): L4-C
By:
— attach evidence otAthority to sign)
t`
Name (typed or printed): Gi%t� ( V
Title:
(CORPORATE SEAL)
Attest:
BROWN PART: SLOPE STABILIZATION IMPROVEMENTS 13
A Joint Venture
Title:
Title:
Name of Joint Venture:
First Joint Venture Name:
(SEAL)
By:
(Signature of first joint venture partner — attach evidence of authority to sign)
Name (typed or printed):
Second Joint Venture Name:
(SEAL)
By:
(Signature of second joint venture partner — attach evidence of authority to sign)
Name (typed or printed):
(Each joint venture must sign. The manner of signing for each individual, partnership,
and corporation that is a party to the joint venture should be in the manner indicated
above.
BROWN PART: SLOPE STABILIZATION IMPROVEMENTS 14
UAKOL, *AMM1,T1111[C1*1;M1J .14(olk1k I J_T4q is], 0
Per Idaho Code, 67-2310, BIDDER shall include in his or her Bid the names and address, and Idaho Public
Works Contractor License Number of the Subcontractors who shall, in the event the Bidder secures the
Contract, subcontract for plumbing, heating and air-conditioning work, and electrical work under the
general Contract. Because no plumbing, heating and air conditioning work is required for this project,
such subcontractors shall not be listed.
In addition to subcontractors for electrical work, provide the names and addresses of the additional
subcontractors, suppliers, individuals or entities called for in the Instruction to Bidders (include Idaho
Public Works Contractor License Numbers for any subcontractors)
Additional Subcontractor Name and Address
Additional Subcontractor Name and Address
010e
Additional Subcontractor Name and Address
4 It,
Public Works License Number
Public Works License Number
Public Works License Number
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS 15
ARTICLE 8 — NON -COLLUSION AFFIDAVIT
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS
McCall, Idaho
CONTRACTOR'S NON -COLLUSION AFFIDAVIT
STATE OF IDAHO
Valley County
/j4 A4-he'&'P a I"�-�'Sl being first duly sworn, deposes and says that he/she is tom'
of rA(VGttiiJ k4A� the party making the foregoing bid; that such
bid is not d in the interest of or on behalf of any undisclosed person, partnership, company,
association, organization, or corporation; that such bid is genuine and not collusive or sham; that said
bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and
has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to
put in a sham bid, nor that anyone shall refrain from bidding; that said bidder has not in any manner,
directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price
of said bidder or of any bidder, nor to fix any overhead, profit, or cost element of such bid price, nor that
of any other bidder, nor secure any advantage against the public body awarding the contract or anyone
interested in the proposed contract; that all statements contained in such bid are true, and, further, that
said bidder has not, directly or indirectly, submitted his bid price or any breakdown thereof, nor the
contents thereof, nor divulged information or data relative thereto, nor paid and will not pay fee in
connection therewith to any corporation, partnership, company, association, organization, bid
depository, nor to any member or agent thereof, nor to any individual, except such person or persons as
have a partnership or other financial interest with aid bidder in is general business.
Signed.
Title: I
�T
Subscribed and sworn to before me this ( G day o40L 20 �v
•�•N•••••� `mil
•u,RY •`':yam % A
Notary Public for
ON . _
Residing at:
�1••._OF___.••�� My Commission Expires: .. 3
BROWN PARE, SLOPE STABILIZATION IMPROI'EMENTS 16
ARTICLE 9 - BID BOND
1. BIDDER (Name and Address):
Falveys LLC
PO Box 710
McCall, ID 83638
2. SURETY (Name and Address of Principal Place of Business):
The Ohio Casualty Insurance Company
175 Berkeley Street
Boston, MA 02116
City of McCall
3. OWNER (Name and Address): 216 E. Park Street
McCall, ID 83638
4. BID:
Bid Due Date: September 15, 2020
Description (project name and location): Brown Park Slope Stabilization Improvements Project
McCall, Idaho
S. BOND
Bond Number: N/A
Date: September 10, 2020
Penal Sum: Five Percent of Bid Amount $ 5.0% of Bid Amount
(Words) (Amount)
IN WITNESS WHEREOF, Surety and Bidder, intending to be legally bound hereby, subject to the terms
printed on the reverse side hereof, do each cause this Bid Bond to be duly executed on its behalf by its
authorized officer, agent, or representative.
6. BIDDER
Falve 's LLC
Bidder's Name and porate
By:
Signet re
- - /'0"
Print Name
Title
Attest:
Signature
Title
SURETY
TASOMCMWAyWoKinsurance Company (Seal)
d Cor ore a Seal
By.
Signature
Jennifer Grenrood
Print Name
Attomey-in-Fad
Title
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS 17
Attest:
Signature
Ellie Peck, Witness
Title
Note: (1) Above addresses are to be used for giving required notice. (2) Any singular reference to Bidder,
Surety, OWNER or other party shall be considered plural where applicable.
Bidder and Surety, jointly and severally, bind themselves, their heirs, executors, administrators,
successors and assigns to pay to OWNER upon default of Bidder the penal sum set forth on the
face of this Bond.
2. Default of Bidder shall occur upon the failure of Bidder to deliver within the time required by the
Bidding Documents (or any extension thereof agreed to In writing by OWNER) the executed
Agreement required by the Bidding Documents and any Performance and Payment Bonds
required by the Bidding Documents.
3. This obligation shall be null and void if:
3.1.OWNER accepts Bidder's Bid and Bidder delivers within the time required by the Bidding
Documents (or any extension thereof agreed to in writing by OWNER) the executed Agreement
required by the Bidding Documents and any Performance and Payment Bonds required by the
Bidding Documents, or
3.2. All Bids are rejected by OWNER, or
3.3.OWNER fails to issue a Notice of Award to Bidder within the time specified in the Bidding
Documents (or any extension thereof agreed to in writing by Bidder and, if applicable,
consented to by Surety when required by paragraph 5 hereof).
4. Payment under this Bond will be due and payable upon default by Bidder and within 30 calendar
days after receipt by Bidder and Surety of written notice of default from OWNER, which notice
will be given with reasonable promptness, identifying this Bond and the Project and including a
statement of the amount due.
S. Surety waives notice of and any and all defenses based on or arising out of anytime extension
to issue Notice of Award agreed to in writing by OWNER and Bidder, provided that the total time
for issuing Notice of Award including extensions shall not in the aggregate exceed 120 days from
Bid due date without Surety's written consent.
6. No suitor action shall be commenced under this Bond prior to 30 calendar days after the notice
of default required in paragraph 4 above is received by Bidder and Surety and in no case later
than one year after Bid due date.
7. Any suitor action under this Bond shall be commenced only in a court of competent jurisdiction
located in the state in which the Project is located.
B. Notices required hereunder shall be in writing and sent to Bidder and Surety at their respective
addresses shown on the face of this Bond. Such notices may be sent by personal delivery,
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS Is
commercial courier or by United States Registered or Certified Mail, return receipt requested,
postage pre -paid, and shall be deemed to be effective upon receipt by the party concerned.
9. Surety shall cause to be attached to this Bond a current and effective Power or Attorney
evidencing the authority of the officer, agent or representative who executed this Bond on
behalf of Surety to execute, seal and deliver such Bond and bind the Surety thereby.
10. This Bond is intended to conform to all applicable statutory requirements. Any applicable
requirement of any applicable statute that has been omitted from this Bond shall be deemed to
be included herein as if set forth at length. If any provision of this Bond conflicts with any
applicable statute, then the provision of said statute shall govern and the remainder of this
Bond that is not in conflict therewith shall continue in full force and effect.
11. The term "Bid" as used herein includes a Bid, offer or proposal.
BROWN PARK SLOPE STABILIZATION IMPROVEMENTS 19
9
w
m
u
This Power of Attorney Nmb the acts of tine named herein. and they have no authority to
bind the Company except In the manner and to the extent herein stated.
Liberty Liberty Mutual Insurance Company
l i 111 c1 i The Ohio Casualty Insurance Company Certilicale No. 8203150 - 9621582
West American Insurance Company
.tsi<r ry
POWER OF ATTORNEY
KNOWN ALL PERSONS By THESE PRESENTS: That The Ohio Casually Insurance Company is a corporation duly oWized under the laws of the State of New Htmpshwe, that
Liberty MAW h rasure Company a s corporation duty crWized under the taws of the State of Massachusetts. and Wass American Insurance Company is a aorporaborr duty orpaw
under the tarns d the State of Indiana (herein odec** caned the lCompariesl paumit to and by authority herein set Iath, does Hereby name. constt►te and appoint
lcunliliy efrrhuaut I the (lock, Kuryl A Richter, Artarnii Stokvvuker
an of the city of I klixc state of t U each ndividualy I there be more than one named, is tue and lawful a8arney rn fact to make,
execute, cued and deliver. for and on its behaN as exsety l un as its ad and deed, any and adertakings, horods, r000gnizances and other surety d*galias, vn pursuance
d presents and preand snob be as tw*9 upon the Companies as it they have been duly sgned by the presiders and attested by the secretary of the Companies in thew own proper
persons
IN WITt1ESS WHEREOF, the pow of Attorney has bast subscribed by an authorized officer or oMcIW of pre Companies and tie corporate tads of (the Calipames have been afted
anaretofh's ?uch divot i:cbrcauy 2020
Liberty Ambit Insurance Company
stemR�- tr INN a� pasty The Ohio Casualty Insurance Company
West A encxn insurance Company
: 1912 1919 ' 1991
4 0
David M. Caraw Asmomt SarrAtary
PENNSYLVAMA
of MONTWKRY
On Iris _uxih day of l Owtur . 2020 before me personally appeared David M. Carey, who adurovdadgod himsel b be the Assistant Secretary of Liberty Mutrai
Companyrif DW Cai uSG C&ia pang. err AiWARIxwicarr Insurance Company. and that he. as such, being authorized so to do, execute the tareWmV instrument for too
irrerain contained by aigrwg on betreH of tie corporalions by himself as a duty authorized offcer.
IN wiTNESS WHEREOF, i have hereutlo subsaibsd my name and affixed my notarial seal at Karp of PruLsswa PainsylvanrQ on the day and year fret above maim
COMMONwFALTH UM PgNWVLVAMA
Mi;rai w.r
iA�an M,.o.iygl Ai,tl Ap,'wreY t'.•rAY By:
Any tiwwwerw f 4AI.al Mtl, h : tl : W 7. i
uuwiM INylltyhAF1A`.t4MN.r11A µAAwla
c4i
v
cc
This Power of Atlorraey is made and executed pursuant to and by aulrodty of the following By4em cued AuMonzatorre or The Ohio Ca AJ* hnwranae company. Liberty Muktai � c
Insurance Companyand west American Insurance Company which resotuions we now in lull face and effect rearing as blows: o %
ARTICLE IV - OFFICERS: Section 12. Pow of Atlomey. ��
Airy dker a other dkkl ot the Corporation auti rized for that purpose in wrting by the Chairman or the President and subject to such finntabolu as Ire Chairman or the -a a
Resident may prescribe, drel appoint such eilameys irrdad, as may be necessary to ad in behet of the Corporation to make, execute, sod, aaarowtedgs and delver as surety S o
any and an undertakings, bonds. recognimices and other surety obigafians. Such attorneys-irgad, subied to the Nnkeions sal tath in their respective powers d attorney. sham m r
have rum poster to bind the Corporation by It* sowlit a and execution of any such instruments and to atfaadu thereto the Beef of the Corporation When so exrecuted, such N
inssrumerns sham be as bmft as I dyed by the President and attested to by the Secretary. Arry power or sufiority granted to any repreeatative or atkxnay4n4ed older the
provrrions of ibis curiae may be revoked at any time by fre Board, the Chairman, t* President or by the officer or officers granting such power or autrority. co
a
ARTICLE XM - Execution of Contracts: SKgm 5. Suety Buda and Undertakings.
Any officer of tie Company authorized for that purpose ii writing by the dhdmmri or the president and subject to such knitaiais as it* dhakmwh or the president may prescribe, e
ehal appoint such ant meysmku-tact has may be necessary to ed in behaK of the Company to make. axearte. east, acknowledge and deliver as surety any orld at undertakaga.
boards, recogriftn ss and ocher suety obigsions. Such a ttornoys-fn-fad subject to the WAS11cns ad bath in their respective powers of Womey. Shen have lost power to bid the
Company by teir signature end exam" of any such Instruments and to attain Mereto the sad of the Company. When so executed such Ins4wnents shal be as bko ft as if
sgnsd by to President and attested by Ire secretary.
Confect of Omngnatlon - The President of to Company, OWN pursuant to the Syiavra of the Company. authorizes David M. Carey. Assistant Secretary to appoint such atomoys sr
twct as may be cocoa" so act an behaft of the Company to make, ezecuts, scat admowledge and deliver as an" any and all undertakings, bonds, recogrrzances and other surety
-
obligiefioris
Authorizataun - By u ammom consent of foe Company's board of Directom the Company consents than facsimile or mechanically reproduced signabire a any assistant secretary of dire
Company, wherever appearing upon a peeled copy of any power of attorney issued by the Company in connection wits surely bonds, shall be valid and brAq upon the Company wiM
the same terce and allied as 11xx* manually shred
i Renee C. Llewellyn, pre andersigrhed, Assistant Secretary, The Ohio casualty ksurance Company, Liberty Minuet Insurance Company, and west American ksurarim Commpany do
thereby c>arity slat On oripinai power of attorney d which the bregdng is a full. true and clxred copy of the Power of A16aney executed by said Comp ernes, is in U force and ellect and
has not been revoked �J�
IN TESTIMONY WHEREOF, i Have hereunto sat (q herd end affixed the seats d acid Cori fenies do is �X d se.
ym-be r as
> s 1912 a 1919 d 1991 O
~d�eh a,xn` s rAa� x�V►ys By:
Renee C. Uowekyri, Assistani�etwy
1 . � M • �
L MS 1_4h7J LUN, OCIC WAIC MIA Co-12M9
A4 fORR CERTIFICATE OF LIABILITY INSURANCE
�,....-�
DATE(MWDO ")
F 5/26/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERnFICATE HOLDER.
IMPORTANT: it the certificate holder Is an ADDITIONAL INSURED, the pollcy{Ns) must be endorsed. It SUBROGATION IS WANED, subject to
the tens and conditions of the policy, certain policies may require an endorsement. A statenint on this certificate does not confer rights to the
certificate holder In Hsu of such endorsement(s).
PRODUCSR
Western Community Ire Co
PO Box 4 M
Pocatello, ID 83205-4848
CONTACT PFOST DAR I N - AA
PHOM 208-401-0 i 2 F MS-232.3W8
E M4A comrnewte@kMns.com
WWR s AFFOROM OOVOMM
Mws
IbMERA: V"em Community Ins Co
39519
e11SURED
III IIIIIIIQII1111II1loll III IIIIIIIIIIIIIIIIIIIIIIii
POBOXIN
MCCALL 1D 83638
INSURER :
INMRC:
INSURER 6:
I P
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER -AFC
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
JaL
TYPE OF ROURANCE
POLICY NUMSER
MaRpyl
UltUrs
A
oEMBAL LUMILITY
CONA ERCIAL Ge* RAL UABII.ITY
CLAIMS.MADE [--xl OCCUR
Y
N
8No841D2
6/21/20
6/21/21
EACH OCCURRENCE
s 1,000,000
pqE
s 100,000
MED EXP Wry ww
S 10,000
PER22NALAAOYMNY
6 1,000,000
GENERAL AGGREGATE
s 2.000.000
2!2 'L AGGREGATE UMT APPLIES PER:
Ix POLICY LOC
PRODUCTS - COMWIOP AGO
$ 2,000,000
s
AREDAR)T06
AUTOMOBILE LIASILRY
ANY AUTO
MUTONEWS'
ANaON
I
N
N
8NO84102
6/21/20
6/21/21
NffUW—
Me s
i O-0--0A 000
8001LY INAMY (Pre pwson)
S
8001LYINMY(Psreoddsno
S
s
UMRELLA LIAR
EXC888L"
OCUR
CLAIMS -MADE
EACH OCCURRENCE
S
AGGREGATE
$
DED IONS
s
1400KERS COMPENBAT001
AND BMN.DYVW LIAMOUTY Y r N
ANY PROPRETpRIPARTNERIE(ECUnVE a
OFFICERlMEMBEREXCLUDED?
11dandgwy In NH)
OE9CRI wM TK7N8 below
N ! A
W STATU- OTH
TORY (d
ELL EACH ACCIDENT
S
EL DISEASE - EA MKOY
s
E.L 01SEASE - POLICY UMn
S
DESCRIPnM OF OPERATMM 1 LOCATIONS I VEHVAS (Altwh ACORD I81. Addhbnsl Remwh Schedule, R more spree Is required)
Refer to IOCG 236(03/07) Exclusion of Coverage for Structures Built Outside of
Designated Areas Endorsement - Copy attached.
III I I I I I I I UI I III I I I I I I I I I 1 I I oil 1 I I 1 I I I I I I I I I I II I Ii
CITY OF MCCALL BUILDING DEPARTMENT
MCCALLPA10 83638
SHOULD ANY OF THE ABOVE DESCRIBEO POLICJE& BE CANCELLED ICE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROWSIONS.
AUTHORIZED REPRESENTATIVE s=-^9//-0
RWKLI ZO (NT VRID) W 1840MIC ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID-
_ LOC #:
A O ADDITIONAL REMARKS SCHEDULE Page Of
AGENCY
Western Community Ins Co
NAMEDINSURED
FALVEYS LLC
PO BOX 710
MCCALL ID 83638
POucraUMBER
CARRIER
NAIL CO
EFFECTIVE DATE;
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER:
CITY OF MCCALL
is listed as an
CG 20 1 O (07/04)
FORM TITLE:
BUILDING DEPARTMENT
additional insured per endorsements
The ACORD name and logo are registered marks of ACORD
►_lil0[:f.T" "T,I
--9014
o=Ac Ro CERTIFICATE OF LIABILITY INSURANCE 020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(8), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT. tf the cartiflaft holder Is an ADDITIONAL INSURED, the poky(ies) must he endorsed. N SUBROGATION tS WAIVED, subject to the
Mane and conditions of the policy. Certain policies may require an endorswenL A statement on this certificate does not confer rights to the
aroficate holder in lieu of such endorsamert(s).
PRODUCER 59
WCT
Farm Insurance Brokerage CO Inc
. 208-232-7914
PO Box 4848
E
Pocatello, ID 83205-4848
INSURE AFFORDIN
OIWpERA:
PMURM
Falveys LLC
Falveys Earthworks
PO Box 710
•IµIRER e :
INSURER c :
INSURER I); Idaho State Insurance Fund
36129
INSURER E t
McCall, ID 83638
INSURER F
MVFRAr:FA CFRTiN:ATF NIIYSLFR• RFVL%Mtd NI/MRFR-
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L
TYPE OF INSURANCE
POLICY NIMAI/RA1
LAWS
GENERA. Likes"
COMMERCNL GENERAL LOMITY
CLASISiMDE ❑ OCCUR
EACH OCCURRENCE
S
{jiEREN`TED
p
S
MED EXP AI a
3
PERSONAL & ADY INJURY
$
GENERAL AGGREGATE
S
oEIR AGGREGATE Lear APPLIES PER:
OR116
POLICY LOCI
PRODUCTS • COMP/OP AGO
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S
AUTOMOBILE LIABILITY
A�K�YpAUTTO
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E
S
s
IrIeReLLA Lw
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EACH OCCURRENCE
$
AGGREGATE
$
DED I I RETENSIONS
S
D
WORKERS COMMUMTNON
AM EMPLOTOW LIABILITY
ANY PROPRETdIRARTSIrd4EJ0ECU7NE Y 1 N
ICIRWIMIER EKZLUCEW
S Yak dtlaia Uwff T pw
M 1 A
616985
07/01 /2020
07101/2021
x TA Tlf-
EA EACH ACCIDENT
S 100,000
E.L. DISEASE - EA EMPLOVEEI
S 100,0w
EL DISEASE . POLICY Leer
I S 500,000
OEDCRWWM OF OPERATIONS A LOCATIONS A VEHICLES tAllaok ACORD101, AddMoad RMaMks ScNodioK E amra spoor ra alquead►
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City Of McCall
ACCORDANCE WITH THE POLICY PROVISIONS.
216 E. Park St.
AUTHOR@G REPRESENTATIVE
McCall, ID 83638
ACORD 25120101081 01988.2010 ACORD CORPORATION. All rk*its reserved.
The ACORD name and logo are registered marks of ACORD.
Idaho'Tax Commission
WH-5 Public Works Contract Report
Sections S*4W4,A and $3-3"9), Idaho Code, require oil Public Mrks Contracts to be re;iorted to the Tait
ComrMaslon. Tlas:/orm must be filed with the Ux Commission within 30 days after a contract is awarded.
Contract awardad by'(DUWX hotly end address)
Gonbract awarded to (eaibecWs r>grne *Ad address)
fate of incorporation
Fetlaral Employer I entificafionNumber (EIN)
Date qual ed to do business in Idaho
$usiners operates as
Cf Sete proprietorship 0 Partnership C Corporaf'son 0 Lt_C
Public Worxs connector ianae numbar
Sol* Ompnetor"s Sociel.se rwmbw
idallo aarealuse tax pemM number
IdahowNibdiding tax pemA number
Awanlin9 a0e+Ky Project number
�M�ourttof c owad
Description and lorAboin of work to be pattonmad
Schedoled project start date: Completion date:
1f the foU Wing infQnrrW on.is not available at this tirna, please indicate elate it will be:
MON
Address Public works cw**c r number
City, state. Zip 0 LLC ❑ Corporation Amount or subcontract
0 Sole eroorietorshIn 0 Partnanihio 1 S
MIL-711a
Er000tse os•+�ae
Use the space below to report, major suppliers of materials and supplies; items removed from inventory; equipment purchased, tented,
or teased for use in project; materials provided by government agency. Please indicate how sales or use tan was paid.
Name
£ederaF EIN
Total value
.r+
Address
Matertais and equiWard.pwChasad and used
city, state, ZIP
ptwrie
Ca Tax paid to supplier 0 Tax paid to slate' G No tax paid
Name
Federal EIN
Totatvalue
Address
Materials and equlpmem purchased and used
city, state, ZIP
Phone
C! Tax pant to supplier ❑Tau paid to state" fl Na tax paid
Name
Federal EIN Total value
Address
Materials and equipmentpuMhased and used
city, Stow ZIP
Phone
ci Tax paid to supplier Q Tax paid to state' 0 No tax paid
Name
t Federal EiN
Total value
Address
Materials and equipment purchased and used
city, State. ZIP Phone
D Tax paid to supplier O Tax paid to state O No talc paid
" If tax was not paid to suppliers btitwas or will be reported as 'items subject to use tax" under your permit number, indicate period of
return on which payment was orwill .be reported:. .
if tax was paid to a state other than Idaho, name state next WOW value" bom(es) above. If tax isdue and has rill previously boon
reported, attaeh.payment to this form. if you need more room, please photocopy this page.
SIGN A ed ar�i8tum Print name hone numberto
MERE
File wMAfte Idaho State Tax.Commission, PO Box 36, Boise ID 83722-2210. For more information, call (208) 334-7618.
Form
W-9
Request for Taxpayer
Give form to the
(Rev. November2005)
Identification Number and Certification
requester. Do not
Department of the Treasury
send to the IRS.
Internal
Revenue Service
N
Name (as shown on your income tax return)
d
rn
m
C-
Business name, if different from above
c
0
q
d
C o
Individual/Exempt
box: ❑ Sole El Corporation ElPartnership ❑ Other ► __________________
from backup
❑
Check appropriate proprietor
withholding
Address (number, street, and apt. or suite no.)
Requester's name and
address (optional)
•� c
a�
City, state, and ZIP code
to
List account numbers here (optional)
m
MIMI Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. 1 am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)
Sign I Signature of
Here U.S. person ► Date ►
Purpose of Form
A person who is required to file an information return with the
IRS, must obtain your correct taxpayer identification number
(TIN) to report, for example, income paid to you, real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
U.S. person. Use Form W-9 only if you are a U.S. person
(including a resident alien), to provide your correct TIN to the
person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a
U.S. exempt payee.
In 3 above, if applicable, you are also certifying that as a
U.S. person, your allocable share of any partnership income
from a U.S. trade or business is not subject to the
withholding tax on foreign partners' share of effectively
connected income.
Note. If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester's form if it is
substantially similar to this Form W-9.
For federal tax purposes, you are considered a person if you
are•
• An individual who is a citizen or resident of the United
States,
• A partnership, corporation, company, or association
created or organized in the United States or under the laws
of the United States, or
• Any estate (other than a foreign estate) or trust. See
Regulations sections 301.7701-6(a) and 7(a) for additional
information.
Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required
to pay a withholding tax on any foreign partners' share of
income from such business. Further, in certain cases where a
Form W-9 has not been received, a partnership is required to
presume that a partner is a foreign person, and pay the
withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to
establish your U.S. status and avoid withholding on your
share of partnership income.
The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding
withholding on its allocable share of net income from the
partnership conducting a trade or business in the United
States is in the following cases:
• The U.S. owner of a disregarded entity and not the entity,
Cat. No. 10231X Form W-9 (Rev. 11-2005)
Form W-9 (Rev. 11-2005)
• The U.S. grantor or other owner of a grantor trust and not
the trust, and
• The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. If you are a foreign person, do not use
Form W-9. Instead, use the appropriate Form W-8 (see
Publication 515, Withholding of Tax on Nonresident Aliens
and Foreign Entities).
Nonresident alien who becomes a resident alien.
Generally, only a nonresident alien individual may use the
terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a
provision known as a "saving clause." Exceptions specified
in the saving clause may permit an exemption from tax to
continue for certain types of income even after the recipient
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an
exception contained in the saving clause of a tax treaty to
claim an exemption from U.S. tax on certain types of income,
you must attach a statement to Form W-9 that specifies the
following five items:
1. The treaty country. Generally, this must be the same
treaty under which you claimed exemption from tax as a
nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under
the terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty
allows an exemption from tax for scholarship income
received by a Chinese student temporarily present in the
United States. Under U.S. law, this student will become a
resident alien for tax purposes if his or her stay in the United
States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30,
1984) allows the provisions of Article 20 to continue to apply
even after the Chinese student becomes a resident alien of
the United States. A Chinese student who qualifies for this
exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax on
his or her scholarship or fellowship income would attach to
Form W-9 a statement that includes the information
described above to support that exemption.
If you are a nonresident alien or a foreign entity not subject
to backup withholding, give the requester the appropriate
completed Form W-8.
What is backup withholding? Persons making certain
payments to you must under certain conditions withhold and
pay to the IRS 28% of such payments (after December 31,
2002). This is called "backup withholding." Payments that
may be subject to backup withholding include interest,
dividends, broker and barter exchange transactions, rents,
royalties, nonemployee pay, and certain payments from
fishing boat operators. Real estate transactions are not
subject to backup withholding.
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make
the proper certifications, and report all your taxable interest
and dividends on your tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part
11 instructions on page 4 for details),
Page 2
3. The IRS tells the requester that you furnished an
incorrect TIN,
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
5. You do not certify to the requester that you are not
subject to backup withholding under 4 above (for reportable
interest and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Also see Special rules regarding partnerships on page 1.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN
to a requester, you are subject to a penalty of $50 for each
such failure unless your failure is due to reasonable cause
and not to willful neglect.
Civil penalty for false information with respect to
withholding. If you make a false statement with no
reasonable basis that results in no backup withholding, you
are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully
falsifying certifications or affirmations may subject you to
criminal penalties including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil
and criminal penalties.
Specific Instructions
Name
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have
changed your last name, for instance, due to marriage
without informing the Social Security Administration of the
name change, enter your first name, the last name shown on
your social security card, and your new last name.
If the account is in joint names, list first, and then circle,
the name of the person or entity whose number you entered
in Part I of the form.
Sole proprietor. Enter your individual name as shown on
your income tax return on the "Name" line. You may enter
your business, trade, or "doing business as (DBA)" name on
the "Business name" line.
Limited liability company (LLC). If you are a single -member
LLC (including a foreign LLC with a domestic owner) that is
disregarded as an entity separate from its owner under
Treasury regulations section 301.7701-3, enter the owner's
name on the "Name" line. Enter the LLC's name on the
"Business name" line. Check the appropriate box for your
filing status (sole proprietor, corporation, etc.), then check
the box for "Other" and enter "LLC" in the space provided.
Other entities. Enter your business name as shown on
required federal tax documents on the "Name" line. This
name should match the name shown on the charter or other
legal document creating the entity. You may enter any
business, trade, or DBA name on the "Business name" line.
Note. You are requested to check the appropriate box for
your status (individual/sole proprietor, corporation, etc.).
Exempt From Backup Withholding
If you are exempt, enter your name as described above and
check the appropriate box for your status, then check the
"Exempt from backup withholding" box in the line following
the business name, sign and date the form.
Form W-9 (Rev. 11-2005) Page 3
Generally, individuals (including sole proprietors) are not
exempt from backup withholding. Corporations are exempt
from backup withholding for certain payments, such as
interest and dividends.
Note. If you are exempt from backup withholding, you
should still complete this form to avoid possible erroneous
backup withholding.
Exempt payees. Backup withholding is not required on any
payments made to the following payees:
1. An organization exempt from tax under section 501(a),
any IRA, or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401(f)(2),
2. The United States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the
United States, or any of their political subdivisions or
instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup
withholding include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register
in the United States, the District of Columbia, or a
possession of the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year
under the Investment Company Act of 1940,
12. A common trust fund operated by a bank under
section 584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or
described in section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through 15.
IF the payment is for ...
THEN the payment is exempt
for...
Interest and dividend payments
All exempt recipients except
for 9
Broker transactions
Exempt recipients 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
Exempt recipients 1 through 5
and patronage dividends
Payments over $600 required
Generally, exempt recipients
2
to be reported and direct
1 through 7
sales over $5,000 1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
z
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys' fees; and
payments for services paid by a federal executive agency.
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
�Iour TIN is your IRS individual taxpayer identification number
TiN). Enter it in the social security number box. If you do
not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that
you use your SSN.
If you are a single -owner LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLC) on page 2), enter your SSN (or EIN, if you have one). If
the LLC is a corporation, partnership, etc., enter the entity's
EIN.
Note. See the chart on page 4 for further clarification of
name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5,
Application for a Social Security Card, from your local Social
Security Administration office or get this form online at
www.socialsecurity.gov. You may also get this form by
calling 1-800-772-1213. Use Form W-7, Application for IRS
Individual Taxpayer Identification Number, to apply for an
ITIN, or Form SS-4, Application for Employer Identification
Number, to apply for an EIN. You can apply for an EIN online
by accessing the IRS website at www.irs.gov/businesses and
clicking on Employer ID Numbers under Related Topics. You
can get Forms W-7 and SS-4 from the IRS by visiting
www.irs.gov or by calling 1-800-TAX-FORM
(1-800-829-3676).
If you are asked to complete Form W-9 but do not have a
TIN, write "Applied For" in the space for the TIN, sign and
date the form, and give it to the requester. For interest and
dividend payments, and certain payments made with respect
to readily tradable instruments, generally you will have 60
days to get a TIN and give it to the requester before you are
subject to backup withholding on payments. The 60-day rule
does not apply to other types of payments. You will be
subject to backup withholding on all such payments until you
provide your TIN to the requester.
Note. Writing "Applied For" means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign
owner must use the appropriate Form W-8.
Form W-9 (Rev. 11-2005) Page 4
Part II. Certification What Name and Number To Give the
To establish to the withholding agent that you are a U.S.
person, or resident alien, sign Form W-9. You may be
requested to sign by the withholding agent even if items 1, 4,
and 5 below indicate otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt recipients, see
Exempt From Backup Withholding on page 2.
Signature requirements. Complete the certification as
indicated in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered
active during 1983. You must give your correct TIN, but you
do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts
considered inactive during 1983. You must sign the
certification or backup withholding will apply. If you are
subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2
in the certification before signing the form.
3. Real estate transactions. You must sign the
certification. You may cross out item 2 of the certification.
4. other payments. You must give your correct TIN, but
you do not have to sign the certification unless you have
been notified that you have previously given an incorrect TIN.
"Other payments" include payments made in the course of
the requester's trade or business for rents, royalties, goods
(other than bills for merchandise), medical and health care
services (including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat
crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529),
IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give
your correct TIN, but you do not have to sign the
certification.
Privacy Act Notice
Requester
For this type of account:
Give name and SSN of:
1. Individual
The individual
2. Two or more individuals (joint
The actual owner of the account
account)
or, if combined funds, the first
individual on the account'
3. Custodian account of a minor
The minor e
(Uniform Gift to Minors Act)
4. a. The usual revocable
The grantor -trustee'
savings trust (grantor is
also trustee)
b. So-called trust account
The actual owner'
that is not a legal or valid
trust under state law
5. Sole proprietorship or
The owner'
single -owner LLC
For this type of account:
Give name and EIN of:
6. Sole proprietorship or
The owner a
single -owner LLC
7. A valid trust, estate, or
Legal entity °
pension trust
8. Corporate or LLC electing
The corporation
corporate status on Form
8832
9. Association, club, religious,
The organization
charitable, educational, or
other tax-exempt organization
10. Partnership or multi -member
The partnership
LLC
11. A broker or registered
The broker or nominee
nominee
12. Account with the Department
The public entity
of Agriculture in the name of
a public entity (such as a
state or local government,
school district, or prison) that
receives agricultural program
payments
List first and circle the name of the person whose number you furnish. If
only one person on a joint account has an SSN, that person's number must
be furnished.
z
Circle the minor's name and furnish the minor's SSN.
J
You must show your individual name and you may also enter your business
or "DBA" name on the second name line. You may use either your SSN or
EIN (if you have one). If you are a sole proprietor, IRS encourages you to
use your SSN.
List first and circle the name of the legal trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the legal
entity itself is not designated in the account title.) Also see Special rules
regarding partnerships on page 1.
Note. If no name is circled when more than one name is
listed, the number will be considered to be that of the first
name listed.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS
uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this
information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat
terrorism.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.