HomeMy Public PortalAbout2021.03.25 -AIP 30 Grant Application - signature documentFAA Form 5100-12
U.S. Department
of Transportation
Federal Aviation
Administration
FAA Form 5100-129, Construction Project Final Acceptance –
Airport Improvement Program Sponsor Certification
Paperwork Reduction Act Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 2120-0569. Public
reporting for this collection of information is estimated to be approximately 8 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, completing and reviewing the collection of information. All responses to this collection of
information are required under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting
requirements of 2 CFR 200. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the Federal Aviation
Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
Clearance Officer, ASP-110.
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-129 (1/1) SUPERSEDES PREVIOUS EDITION page 1 of 3
U.S. Department of Transportation
Federal Aviation Administration
OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 8/31/2019
Construction Project Final Acceptance
Airport Improvement Program Sponsor Certification
Sponsor:
Airport:
Project Number:
Description of Work:
Application
49 USC § 47105(d), authorizes the Secretary to require me certification from the sponsor that it will
comply with the statutory and administrative requirements in carrying out a project under the Airport
Improvement Program. General standards for final acceptance and close out of federally funded
construction projects are in 2 CFR § 200.343 – Closeout and supplemented by FAA Order 5100.38. The
sponsor must determine that project costs are accurate and proper in accordance with specific
requirements of the grant agreement and contract documents.
Certification Statements
Except for certification statements below marked not applicable (N/A), this list includes major
requirements of the construction project. Selecting “<es” represents sponsor DFNQRZOHGJPHQW and
confirmation of the certification statement. The term “will” means Sponsor action taken at appropriate
time based on the certification statement focus area, but no later than the end of the project period of
performance. This list is not comprehensive and does not relieve the sponsor from fully complying with
all applicable statutory and administrative standards. The source of the requirement is referenced within
parenthesis.
1.The personnel engaged in project administration, engineering supervision, project inspection, and
acceptance testing were or will be determined to be qualified and competent to perform the work
(Grant Assurance).
Yes No N/A
2. Construction records, including daily logs, were or will be kept by the resident
engineer/construction inspector that fully document contractor’s performance in complying with:
a. Technical standards (Advisory Circular (AC) 150/5370-12);
b.Contract requirements (2 CFR part 200 and FAA Order 5100.38); and
c. Construction safety and phasing plan measures (AC 150/5370-2).
Yes No N/A
3. All acceptance tests specified in the project specifications were or will be performed and
documented. (AC 150/5370-12).
Yes No N/A
City of McCall, Idaho
McCall Municipal Airport
AIP 3-16-0023-030-2021
Construct East-West Taxiway (Design Only)
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-129 (1/1) SUPERSEDES PREVIOUS EDITION page 2 of 3
4. Sponsor has taken or will take appropriate corrective action for any test result outside of
allowable tolerances (AC 150/5370-12).
Yes No N/A
5. Pay reduction factors required by the specifications were applied or will be applied in computing
final payments with a summary made available to the FAA (AC 150/5370-10).
Yes No N/A
6. Sponsor has notified, or will promptly notify the Federal Aviation Administration (FAA) of the
following occurrences:
a. Violations of any federal requirements set forth or included by reference in the contract
documents (2 CFR part 200);
b. Disputes or complaints concerning federal labor standards (29 CFR part 5); and
c.Violations of or complaints addressing conformance with Equal Employment Opportunity or
Disadvantaged Business Enterprise requirements (41 CFR Chapter 60 and 49 CFR part 26).
Yes No N/A
7. Weekly payroll records and statements of compliance were or will be submitted by the prime
contractor and reviewed by the sponsor for conformance with federal labor and civil rights
requirements as required by FAA and U.S. Department of Labor (29 CFR Part 5).
Yes No N/A
8. Payments to the contractor were or will be made in conformance with federal requirements and
contract provisions using sponsor internal controls that include:
a. Retaining source documentation of payments and verifying contractor billing statements
against actual performance (2 CFR § 200.302 and FAA Order 5100.38);
b. Prompt payment of subcontractors for satisfactory performance of work (49 CFR § 26.29);
c. Release of applicable retainage upon satisfactory performance of work (49 CFR § 26.29);
and
d. Verification that payments to DBEs represent work the DBE performed by carrying out a
commercially useful function (49 CFR §26.55).
Yes No N/A
9. A final project inspection was or will be conducted with representatives of the sponsor and the
contractor present that ensure:
a. Physical completion of project work in conformance with approved plans and specifications
(Order 5100.38);
b. Necessary actions to correct punch list items identified during final inspection are complete
(Order 5100.38); and
c. Preparation of a record of final inspection and distribution to parties to the contract
(Order 5100.38);
Yes No N/A
10. The project was or will be accomplished without material deviations, changes, or modifications
from approved plans and specifications, except as approved by the FAA (Order 5100.38).
Yes No N/A
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-129 (1/1) SUPERSEDES PREVIOUS EDITION page 3 of 3
Yes No N/A
12. For development projects, sponsor has taken or will take the following close-out actions:
a. Submit to the FAA a final test and quality assurance report summarizing acceptance test
results, as applicable (Grant Condition);
b. Complete all environmental requirements as established within the project environmental
determination (Oder 5100.38); and
c. Prepare and retain as-built plans (Order 5100.38).
Yes No N/A
13. Sponsor has revised or will revise their airport layout plan (ALP) that reflects improvements made
and has submitted or will submit an updated ALP to the FAA no later than 90 days from the
period of performance end date. (49 USC § 47107 and Order 5100.38).
Yes No N/A
Attach documentation clarifying any above item marked with “No” response.
Sponsor’s Certification
I certify, for the project identified herein, responses to the forgoing items are accurate as marked and
additional documentation for any item marked “no” is correct and complete.
Executed on this day of , .
Name of Sponsor:
Name of Sponsor’s Authorized Official:
Title of Sponsor’s Authorized Official:
Signature of Sponsor’s Authorized Official:
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
11. The construction of all buildings have complied or will comply with the seismic construction
requirements of 49 CFR § 41.120.
City of McCall, Idaho
Robert S. Giles
Mayor, City of McCall
25 March 2021
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-130
U.S. Department
of Transportation
Federal Aviation
Administration
FAA Form 5100-130, Drug-Free Workplace – Airport Improvement
Program Sponsor Certification
Paperwork Reduction Act Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 2120-0569. Public
reporting for this collection of information is estimated to be approximately 8 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, completing and reviewing the collection of information. All responses to this collection of
information are required under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting
requirements of 2 CFR 200. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the Federal Aviation
Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
Clearance Officer, ASP-110.
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-130 (1/1) SUPERSEDES PREVIOUS EDITION Page 1 of 3
U.S. Department of Transportation
Federal Aviation Administration
OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 8/31/2019
Drug-Free Workplace
Airport Improvement Program Sponsor Certification
Sponsor:
Airport:
Project Number:
Description of Work:
Application
49 USC § 47105(d) authorizes the Secretary to require certification from the sponsor that it will comply
with the statutory and administrative requirements in carrying out a project under the Airport Improvement
Program (AIP). General requirements on the drug-free workplace within federal grant programs are
described in 2 CFR part 182. Sponsors are required to certify they will be, or will continue to provide, a
drug-free workplace in accordance with the regulation. The AIP project grant agreement contains specific
assurances on the Drug-Free Workplace Act of 1988.
Certification Statements
Except for certification statements below marked as not applicable (N/A), this list includes major
requirements of the construction project. Selecting “Yes” represents sponsor acknowledgement and
confirmation of the certification statement. The term “will” means Sponsor action taken at appropriate time
based on the certification statement focus area, but no later than the end of the project period of
performance. This list is not comprehensive and does not relieve the sponsor from fully complying with all
applicable statutory and administrative standards. The source of the requirement is referenced within
parenthesis.
1. A statement has been or will be published prior to commencement of project notifying employees
that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled
substance is prohibited in the sponsor's workplace, and specifying the actions to be taken against
employees for violation of such prohibition (2 CFR § 182.205).
Yes No N/A
2. An ongoing drug-free awareness program (2 CFR § 182.215) has been or will be established
prior to commencement of project to inform employees about:
a. The dangers of drug abuse in the workplace;
b. The sponsor's policy of maintaining a drug-free workplace;
c.Any available drug counseling, rehabilitation, and employee assistance programs; and
d. The penalties that may be imposed upon employees for drug abuse violations occurring
in the workplace.
Yes No N/A
City of McCall, Idaho
McCall Municipal Airport
AIP 3-16-0023-030-2021
Construct East-West Taxiway (Design Only)
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-130 (1/1) SUPERSEDES PREVIOUS EDITION Page 2 of 3
3. Each employee to be engaged in the performance of the work has been or will be given a copy of
the statement required within item 1 above prior to commencement of project (2 CFR § 182.210).
Yes No N/A
4. Employees have been or will be notified in the statement required by item 1 above that, as a
condition employment under the grant (2 CFR § 182.205(c)), the employee will:
a. Abide by the terms of the statement; and
b. Notify the employer in writing of his or her conviction for a violation of a criminal drug
statute occurring in the workplace no later than five calendar days after such conviction.
Yes No N/A
5. The Federal Aviation Administration (FAA) will be notified in writing within 10 calendar days after
receiving notice under item 4b above from an employee or otherwise receiving actual notice of
such conviction (2 CFR § 182.225). Employers of convicted employees must provide notice,
including position title of the employee, to the FAA (2 CFR § 182.300).
Yes No N/A
6. One of the following actions (2 CFR § 182.225(b)) will be taken within 30 calendar days of
receiving a notice under item 4b above with respect to any employee who is so convicted:
a. Take appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; and
b. Require such employee to participate satisfactorily in drug abuse assistance or
rehabilitation programs approved for such purposes by a federal, state, or local health,
law enforcement, or other appropriate agency.
Yes No N/A
7. A good faith effort will be made, on a continuous basis, to maintain a drug-free workplace through
implementation of items 1 through 6 above (2 CFR § 182.200).
Yes No N/A
Site(s) of performance of work (2 CFR § 182.230):
Location 1
Name of Location:
Address:
Location 2 (if applicable)
Name of Location:
Address:
Location 3 (if applicable)
Name of Location:
Address:
McCall Muncicpal Airport
336 Deinhard Ln, McCall, ID 83638
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-130 (1/1) SUPERSEDES PREVIOUS EDITION Page 3 of 3
Attach documentation clarifying any above item marked with a “No” response.
Sponsor’s Certification
I certify, for the project identified herein, responses to the forgoing items are accurate as marked and
additional documentation for any item marked “no” is correct and complete.
Executed on this day of , .
Name of Sponsor:
Name of Sponsor’s Authorized Official:
Title of Sponsor’s Authorized Official:
Signature of Sponsor’s Authorized Official:
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
City of McCall, Idaho
Robert S. Giles
Mayor, City of McCall
25 March 2021
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-131
U.S. Department
of Transportation
Federal Aviation
Administration
FAA Form 5100-131, Equipment and Construction Contracts –
Airport Improvement Sponsor Certification
Paperwork Reduction Act Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 2120-0569. Public
reporting for this collection of information is estimated to be approximately 8 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, completing and reviewing the collection of information. All responses to this collection of
information are required under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting
requirements of 2 CFR 200. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the Federal Aviation
Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
Clearance Officer, ASP-110.
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-131 (1/1) SUPERSEDES PREVIOUS EDITION Page 1 of 4
U.S. Department of Transportation
Federal Aviation Administration
OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 8/31/2019
Equipment and Construction Contracts
Airport Improvement Sponsor Certification
Sponsor:
Airport:
Project Number:
Description of Work:
Application
49 USC § 47105(d) authorizes the Secretary to require certification from the sponsor that it will comply
with the statutory and administrative requirements in carrying out a project under the Airport Improvement
Program (AIP). General procurement standards for equipment and construction contracts within Federal
grant programs are described in 2 CFR §§ 200.317-200.326. Labor and Civil Rights Standards
applicable to the AIP are established by the Department of Labor (www.dol.gov) AIP Grant Assurance
C.1—General Federal Requirements identifies all applicable Federal Laws, regulations, executive orders,
policies, guidelines and requirements for assistance under the AIP. Sponsors may use state and local
procedures provided the procurement conforms to these federal standards.
This certification applies to all equipment and construction projects. Equipment projects may or may not
employ laborers and mechanics that qualify the project as a “covered contract” under requirements
established by the Department of Labor requirements. Sponsor shall provide appropriate responses to
the certification statements that reflect the character of the project regardless of whether the contract is
for a construction project or an equipment project.
Certification Statements
Except for certification statements below marked as not applicable (N/A), this list includes major
requirements of the construction project. Selecting “Yes” represents sponsor acknowledgement and
confirmation of the certification statement. The term “will” means Sponsor action taken at appropriate
time based on the certification statement focus area, but no later than the end of the project period of
performance. This list is not comprehensive and does not relieve the sponsor from fully complying with all
applicable statutory and administrative standards. The source of the requirement is referenced within
parenthesis.
1. A written code or standard of conduct is or will be in effect prior to commencement of the project
that governs the performance of the sponsor’s officers, employees, or agents in soliciting,
awarding and administering procurement contracts (2 CFR § 200.318).
Yes No N/A
City of McCall, Idaho
McCall Municipal Airport
AIP 3-16-0023-030-2021
Construct East-West Taxiway (Design Only)
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-131 (1/1) SUPERSEDES PREVIOUS EDITION Page 2 of 4
2. For all contracts, qualified and competent personnel are or will be engaged to perform contract
administration, engineering supervision, construction inspection, and testing
(Grant Assurance C.17).
Yes No N/A
3. Sponsors that are required to have a Disadvantage Business Enterprise (DBE) program on file
with the FAA have included or will include clauses required by Title VI of the Civil Rights Act and
49 CFR Part 26 for Disadvantaged Business Enterprises in all contracts and subcontracts.
Yes No N/A
4. Sponsors required to have a DBE program on file with the FAA have implemented or will
implement monitoring and enforcement measures that:
a. Ensure work committed to Disadvantaged Business Enterprises at contract award is
actually performed by the named DBEs (49 CFR § 26.37(b));
b.Include written certification that the sponsor has reviewed contract records and has
monitored work sites for performance by DBE firms (49 CFR § 26.37(b)); and
c. Provides for a running tally of payments made to DBE firms and a means for comparing
actual attainments (i.e. payments) to original commitments (49 CFR § 26.37(c)).
Yes No N/A
5. Sponsor procurement actions using the competitive sealed bid method (2 CFR § 200.320(c)). was
or will be:
a. Publicly advertised, allowing a sufficient response time to solicit an adequate number of
interested contractors or vendors;
b. Prepared to include a complete, adequate and realistic specification that defines the
items or services in sufficient detail to allow prospective bidders to respond;
c. Publicly opened at a time and place prescribed in the invitation for bids; and
d. Prepared in a manner that result in a firm fixed price contract award to the lowest
responsive and responsible bidder.
Yes No N/A
6. For projects the Sponsor proposes to use the competitive proposal procurement method (2 CFR §
200.320(d)), Sponsor has requested or will request FAA approval prior to proceeding with a
competitive proposal procurement by submitting to the FAA the following:
a. Written justification that supports use of competitive proposal method in lieu of the
preferred sealed bid procurement method;
b. Plan for publicizing and soliciting an adequate number of qualified sources; and
c. Listing of evaluation factors along with relative importance of the factors.
Yes No N/A
7. For construction and equipment installation projects, the bid solicitation includes or will include the
current federal wage rate schedule(s) for the appropriate type of work classifications (2 CFR Part
200, Appendix II).
Yes No N/A
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-131 (1/1) SUPERSEDES PREVIOUS EDITION Page 3 of 4
8. Concurrence was or will be obtained from the Federal Aviation Administration (FAA) prior to
contract award under any of the following circumstances (Order 5100.38D):
a. Only one qualified person/firm submits a responsive bid;
b. Award is to be made to other than the lowest responsible bidder; and
c. Life cycle costing is a factor in selecting the lowest responsive bidder.
Yes No N/A
9. All construction and equipment installation contracts contain or will contain provisions for:
a. Access to Records (§ 200.336)
b. Buy American Preferences (Title 49 U.S.C. § 50101)
c. Civil Rights - General Provisions and Title VI Assurances( 41 CFR part 60)
d.Federal Fair Labor Standards (29 U.S.C. § 201, et seq)
e. Occupational Safety and Health Act requirements (20 CFR part 1920)
f. Seismic Safety – building construction (49 CFR part 41)
g.State Energy Conservation Requirements - as applicable(2 CFR part 200, Appendix II)
h. U.S. Trade Restriction (49 CFR part 30)
i. Veterans Preference (49 USC § 47112(c))
Yes No N/A
10. All construction and equipment installation contracts exceeding $2,000 contain or will contain the
provisions established by:
a. Davis-Bacon and Related Acts (29 CFR part 5)
b. Copeland “Anti-Kickback” Act (29 CFR parts 3 and 5)
Yes No N/A
11.All construction and equipment installation contracts exceeding $3,000 contain or will contain a
contract provision that discourages distracted driving (E.O. 13513).
Yes No N/A
12. All contracts exceeding $10,000 contain or will contain the following provisions as applicable:
a. Construction and equipment installation projects - Applicable clauses from
41 CFR Part 60 for compliance with Executive Orders 11246 and 11375 on Equal
Employment Opportunity;
b. Construction and equipment installation - Contract Clause prohibiting segregated facilities
in accordance with 41 CFR part 60-1.8;
c. Requirement to maximize use of products containing recovered materials in accordance
with 2 CFR § 200.322 and 40 CFR part 247; and
d. Provisions that address termination for cause and termination for convenience
(2 CFR Part 200, Appendix II).
Yes No N/A
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-131 (1/1) SUPERSEDES PREVIOUS EDITION Page 4 of 4
13. All contracts and subcontracts exceeding $25,000: Measures are in place or will be in place (e.g.
checking the System for Award Management) that ensure contracts and subcontracts are not
awarded to individuals or firms suspended, debarred, or excluded from participating in federally
assisted projects (2 CFR parts 180 and 1200).
Yes No N/A
14. Contracts exceeding the simplified acquisition threshold (currently $150,000) include or will include
provisions, as applicable, that address the following:
a. Construction and equipment installation contracts - a bid guarantee of 5%, a performance
bond of 100%, and a payment bond of 100% (2 CFR § 200.325);
b. Construction and equipment installation contracts - requirements of the Contract Work
Hours and Safety Standards Act (40 USC 3701-3708, Sections 103 and 107);
c. Restrictions on Lobbying and Influencing (2 CFR part 200, Appendix II);
d. Conditions specifying administrative, contractual and legal remedies for instances where
contractor of vendor violate or breach the terms and conditions of the contract (2 CFR
§200, Appendix II); and
e. All Contracts - Applicable standards and requirements issued under Section 306 of the
Clean Air Act (42 USC 7401-7671q), Section 508 of the Clean Water Act (33 USC 1251-
1387, and Executive Order 11738.
Yes No N/A
Attach documentation clarifying any above item marked with “No” response.
Sponsor’s Certification
I certify, for the project identified herein, responses to the forgoing items are accurate as marked and
additional documentation for any item marked “no” is correct and complete.
Executed on this day of , .
Name of Sponsor:
Name of Sponsor’s Authorized Official:
Title of Sponsor’s Authorized Official:
Signature of Sponsor’s Authorized Official:
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
City of McCall, Idaho
Robert S. Giles
Mayor, City of McCall
25 March 2021
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-132
U.S. Department
of Transportation
Federal Aviation
Administration
FAA Form 5100-132, Project Plans and Specifications – Airport
Improvement Program Sponsor Certification
Paperwork Reduction Act Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 2120-0569. Public
reporting for this collection of information is estimated to be approximately 8 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, completing and reviewing the collection of information. All responses to this collection of
information are required under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting
requirements of 2 CFR 200. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the Federal Aviation
C
Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
learance Officer, ASP-110.
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-132 (1/1) SUPERSEDES PREVIOUS EDITION Page 1 of 3
U.S. Department of Transportation
Federal Aviation Administration
OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 8/31/2019
Project Plans and Specifications
Airport Improvement Program Sponsor Certification
Sponsor:
Airport:
Project Number:
Description of Work:
Application
49 USC § 47105(d) authorizes the Secretary to require certification from the sponsor that it will comply
with the statutory and administrative requirements in carrying out a project under the Airport Improvement
Program (AIP). Labor and civil rights standards applicable to AIP are established by the Department of
Labor (www.dol.gov/). AIP Grant Assurance C.1—General Federal Requirements identifies applicable
federal laws, regulations, executive orders, policies, guidelines and requirements for assistance under
AIP. A list of current advisory circulars with specific standards for procurement, design or construction of
airports, and installation of equipment and facilities is referenced in standard airport sponsor Grant
Assurance 34 contained in the grant agreement.
Certification Statements
Except for certification statements below marked as not applicable (N/A), this list includes major
requirements of the construction project. Selecting “Yes” represents sponsor acknowledgement and
confirmation of the certification statement. The term “will” means Sponsor action taken at appropriate
time based on the certification statement focus area, but no later than the end of the project period of
performance. This list is not comprehensive and does not relieve the sponsor from fully complying with all
applicable statutory and administrative standards. The source of the requirement is referenced within
parenthesis.
1. The plans and specifications were or will be prepared in accordance with applicable federal
standards and requirements, so that no deviation or modification to standards set forth in the
advisory circulars, or FAA-accepted state standard, is necessary other than those explicitly
approved by the Federal Aviation Administration (FAA) (14 USC § 47105).
Yes No N/A
2. Specifications incorporate or will incorporate a clear and accurate description of the technical
requirement for the material or product that does not contain limiting or proprietary features that
unduly restrict competition (2 CFR §200.319).
Yes No N/A
City of McCall, Idaho
McCall Municipal Airport
AIP 3-16-0023-030-2021
Construct East-West Taxiway (Design Only)
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-132 (1/1) SUPERSEDES PREVIOUS EDITION Page 2 of 3
3. The development that is included or will be included in the plans is depicted on the current airport
layout plan as approved by the FAA (14 USC § 47107).
Yes No N/A
4. Development and features that are ineligible or unallowable for AIP funding have been or will be
omitted from the plans and specifications (FAA Order 5100.38, par. 3-43).
Yes No N/A
5. The specification does not use or will not use “brand name” or equal to convey requirements
unless sponsor requests and receives approval from the FAA to use brand name (FAA Order
5100.38, Table U-5).
Yes No N/A
6. The specification does not impose or will not impose geographical preference in their
procurement requirements (2 CFR §200.319(b) and FAA Order 5100.38, Table U-5).
Yes No N/A
7. The use of prequalified lists of individuals, firms or products include or will include sufficient
qualified sources that ensure open and free competition and that does not preclude potential
entities from qualifying during the solicitation period (2 CFR §319(d)).
Yes No N/A
8. Solicitations with bid alternates include or will include explicit information that establish a basis for
award of contract that is free of arbitrary decisions by the sponsor (2 CFR § 200.319(a)(7)).
Yes No N/A
9. Concurrence was or will be obtained from the FAA if Sponsor incorporates a value engineering
clause into the contract (FAA Order 5100.38, par. 3-57).
Yes No N/A
10. The plans and specifications incorporate or will incorporate applicable requirements and
recommendations set forth in the federally approved environmental finding (49 USC §47106(c)).
Yes No N/A
11. The design of all buildings comply or will comply with the seismic design requirements of 49 CFR
§ 41.120. (FAA Order 5100.38d, par. 3-92)
Yes No N/A
12. The project specification include or will include process control and acceptance tests required for
the project by as per the applicable standard:
a. Construction and installation as contained in Advisory Circular (AC) 150/5370-10.
Yes No N/A
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-132 (1/1) SUPERSEDES PREVIOUS EDITION Page 3 of 3
b. Snow Removal Equipment as contained in AC 150/5220-20.
Yes No N/A
c. Aircraft Rescue and Fire Fighting (ARFF) vehicles as contained in AC 150/5220-10.
Yes No N/A
For construction activities within or near aircraft operational areas(AOA):
DThe Sponsor has or will prepare a construction safety and phasing plan (CSPP) conforming
to Advisory Circular 150/5370-2.
ECompliance with CSPP safety provisions has been or will be incorporated into the plans
and specifications as a contractor requirement.
FSponsor will not initiate work until receiving FAA’s concurrence with the CSPP (FAA Order
5100.38, Par. 5-29).
Yes No N/A
14. The project was or will be physically completed without federal participation in costs due to errors
and omissions in the plans and specifications that were foreseeable at the time of project design
(49 USC §47110(b)(1) and FAA Order 5100.38d, par. 3-100).
Yes No N/A
Attach documentation clarifying any above item marked with “No” response.
Sponsor’s Certification
I certify, for the project identified herein, responses to the forgoing items are accurate as marked and
additional documentation for any item marked “no” is correct and complete.
Executed on this day of , .
Name of Sponsor:
Name of Sponsor’s Authorized Official:
Title of Sponsor’s Authorized Official:
Signature of Sponsor’s Authorized Official:
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
City of McCall, Idaho
Robert S. Giles
Mayor, City of McCall
25 March 2021
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-133
U.S. Department
of Transportation
Federal Aviation
Administration
FAA FRUP 5100-133, RHDO PURSHUW\ AFTXLVLWLRQ –
$LUSRUW,PSURYHPHQW3URJUDP6SRQVRU&HUWLILFDWLRQ
Paperwork Reduction Act Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 2120-0569. Public
reporting for this collection of information is estimated to be approximately 8 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, completing and reviewing the collection of information. All responses to this collection of
information are required under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting
requirements of 2 CFR 200. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the Federal Aviation
Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
Clearance Officer, ASP-110.
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-133 (1/17) SUPERSEDES PREVIOUS EDITION Page 1 of 3
U.S. Department of Transportation
Federal Aviation Administration
OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 8/31/2019
Real Property Acquisition
Airport Improvement Program Sponsor Certification
Sponsor:
Airport:
Project Number:
Description of Work:
Application
49 USC § 47105(d) authorizes the Secretary to require certification from the sponsor that it will comply
with the statutory and administrative requirements in carrying out a project under the Airport Improvement
Program (AIP). General requirements on real property acquisition and relocation assistance are in
49 CFR Part 24. The AIP project grant agreement contains specific requirements and assurances on the
Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (Uniform Act), as
amended.
Certification Statements
Except for certification statements below marked not applicable (N/A), this list includes major
requirements of the real property acquisition project. Selecting “Yes” represents sponsor
acknowledgement and confirmation of the certification statement. The term “will” means Sponsor action
taken at appropriate time based on the certification statement focus area, but no later than the end of the
project period of performance. This list is not comprehensive and does not relieve the sponsor from fully
complying with all applicable statutory and administrative standards.
1.The sponsor’s attorney or other official has or will have good and sufficient title as well as title
evidence on property in the project.
Yes No N/A
2.If defects and/or encumbrances exist in the title that adversely impact the sponsor’s intended use
of property in the project, they have been or will be extinguished, modified, or subordinated.
Yes No N/A
3.If property for airport development is or will be leased, the following conditions have been met:
a.The term is for 20 years or the useful life of the project;
b.The lessor is a public agency; and
c.The lease contains no provisions that prevent full compliance with the grant agreement.
Yes No N/A
City of McCall, Idaho
McCall Municipal Airport
AIP 3-16-0023-030-2021
Construct East-West Taxiway (Design Only)
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-133 (1/17) SUPERSEDES PREVIOUS EDITION Page 2 of 3
4.Property in the project is or will be in conformance with the current Exhibit A property map, which
is based on deeds, title opinions, land surveys, the approved airport layout plan, and project
documentation.
Yes No N/A
5.For any acquisition of property interest in noise sensitive approach zones and related areas,
property interest was or will be obtained to ensure land is used for purposes compatible with
noise levels associated with operation of the airport.
Yes No N/A
6.For any acquisition of property interest in runway protection zones and areas related to
14 CFR 77 surfaces or to clear other airport surfaces, property interest was or will be obtained for
the following:
a.The right of flight;
b.The right of ingress and egress to remove obstructions; and
c.The right to restrict the establishment of future obstructions.
Yes No N/A
7.Appraisals prepared by qualified real estate appraisers hired by the sponsor include or will
include the following:
a.Valuation data to estimate the current market value for the property interest acquired on
each parcel; and
b.Verification that an opportunity has been provided to the property owner or representative
to accompany appraisers during inspections.
Yes No N/A
8.Each appraisal has been or will be reviewed by a qualified review appraiser to recommend an
amount for the offer of just compensation, and the written appraisals as well as review appraisal
are available to Federal Aviation Administration (FAA) for review.
Yes No N/A
9.A written offer to acquire each parcel was or will be presented to the property owner for not less
than the approved amount of just compensation.
Yes No N/A
10.Effort was or will be made to acquire each property through the following negotiation procedures:
a.No coercive action to induce agreement; and
b.Supporting documents for settlements included in the project files.
Yes No N/A
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-133 (1/17) SUPERSEDES PREVIOUS EDITION Page 3 of 3
11. If a negotiated settlement is not reached, the following procedures were or will be used:
a. Condemnation initiated and a court deposit not less than the just compensation made
prior to possession of the property; and
b.Supporting documents for awards included in the project files.
Yes No N/A
12. If displacement of persons, businesses, farm operations, or non-profit organizations is involved, a
relocation assistance program was or will be established, with displaced parties receiving general
information on the program in writing, including relocation eligibility, and a 90-day notice to
vacate.
Yes No N/A
13. Relocation assistance services, comparable replacement housing, and payment of necessary
relocation expenses were or will be provided within a reasonable time period for each displaced
occupant in accordance with the Uniform Act.
Yes No N/A
Attach documentation clarifying any above item marked with “No” response.
Sponsor’s Certification
I certify, for the project identified herein, responses to the forgoing items are accurate as marked and
additional documentation for any item marked “no” is correct and complete.
Executed on this day of , .
Name of Sponsor:
Name of Sponsor’s Authorized Official:
Title of Sponsor’s Authorized Official:
Signature of Sponsor’s Designated Official Representative:
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
City of McCall, Idaho
Robert S. Giles
Mayor, City of McCall
25 March 2021
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-134
U.S. Department
of Transportation
Federal Aviation
Administration
FAA Form 5100-134, Selection of Consultants – Airport
Improvement Program Sponsor Certification
Paperwork Reduction Act Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 2120-0569. Public
reporting for this collection of information is estimated to be approximately 8 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, completing and reviewing the collection of information. All responses to this collection of
information are required under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting
requirements of 2 CFR 200. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the Federal Aviation
Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
Clearance Officer, ASP-110.
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-134 (/17) SUPERSEDES PREVIOUS EDITION Page 1 of 3
U.S. Department of Transportation
Federal Aviation Administration
OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 8/31/2019
Selection of Consultants
Airport Improvement Program Sponsor Certification
Sponsor:
Airport:
Project Number:
Description of Work:
Application
49 USC § 47105(d) authorizes the Secretary to require certification from the sponsor that it will comply
with the statutory and administrative requirements in carrying out a project under the Airport Improvement
Program (AIP). General requirements for selection of consultant services within federal grant programs
are described in 2 CFR §§ 200.317-200.326. Sponsors may use other qualifications-based procedures
provided they are equivalent to standards of Title 40 chapter 11 and FAA Advisory Circular 150/5100-14,
Architectural, Engineering, and Planning Consultant Services for Airport Grant Projects.
Certification Statements
Except for certification statements below marked as not applicable (N/A), this list includes major
requirements of the construction project. Selecting “Yes” represents sponsor acknowledgement and
confirmation of the certification statement. The term “will” means Sponsor action taken at appropriate time
based on the certification statement focus area, but no later than the end of the project period of
performance. This list is not comprehensive and does not relieve the sponsor from fully complying with all
applicable statutory and administrative standards. The source of the requirement is referenced within
parenthesis.
1. Sponsor acknowledges their responsibility for the settlement of all contractual and administrative
issues arising out of their procurement actions (2 CFR § 200.318(k)).
Yes No N/A
2. Sponsor procurement actions ensure or will ensure full and open competition that does not
unduly limit competition (2 CFR § 200.319).
Yes No N/A
3. Sponsor has excluded or will exclude any entity that develops or drafts specifications,
requirements, or statements of work associated with the development of a request-for-
qualifications (RFQ) from competing for the advertised services (2 CFR § 200.319).
Yes No N/A
City of McCall, Idaho
McCall Municipal Airport
AIP 3-16-0023-030-2021
Construct East-West Taxiway (Design Only)
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-134 (/17) SUPERSEDES PREVIOUS EDITION Page 2 of 3
4. The advertisement describes or will describe specific project statements-of-work that provide
clear detail of required services without unduly restricting competition (2 CFR § 200.319).
Yes No N/A
5. Sponsor has publicized or will publicize a RFQ that:
a. Solicits an adequate number of qualified sources (2 CFR § 200.320(d)); and
b. Identifies all evaluation criteria and relative importance (2 CFR § 200.320(d)).
Yes No N/A
6. Sponsor has based or will base selection on qualifications, experience, and disadvantaged
business enterprise participation with price not being a selection factor (2 CFR § 200.320(d)).
Yes No N/A
7. Sponsor has verified or will verify that agreements exceeding $25,000 are not awarded to
individuals or firms suspended, debarred or otherwise excluded from participating in federally
assisted projects (2 CFR §180.300).
Yes No N/A
8. A/E services covering multiple projects: Sponsor has agreed to or will agree to:
a. Refrain from initiating work covered by this procurement beyond five years from the date
of selection (AC 150/5100-14); and
b. Retain the right to conduct new procurement actions for projects identified or not
identified in the RFQ (AC 150/5100-14).
Yes No N/A
9. Sponsor has negotiated or will negotiate a fair and reasonable fee with the firm they select as
most qualified for the services identified in the RFQ (2 CFR § 200.323).
Yes No N/A
10. The Sponsor’s contract identifies or will identify costs associated with ineligible work separately
from costs associated with eligible work (2 CFR § 200.302).
Yes No N/A
11. Sponsor has prepared or will prepare a record of negotiations detailing the history of the
procurement action, rationale for contract type and basis for contract fees (2 CFR §200.318(i)).
Yes No N/A
12. Sponsor has incorporated or will incorporate mandatory contact provisions in the consultant
contract for AIP-assisted work (49 U.S.C. Chapter 471 and 2 CFR part 200 Appendix II)
Yes No N/A
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-134 (/17) SUPERSEDES PREVIOUS EDITION Page 3 of 3
13. For contracts that apply a time-and-material payment provision (also known as hourly rates,
specific rates of compensation, and labor rates), the Sponsor has established or will establish:
a. Justification that there is no other suitable contract method for the services (2 CFR
§200.318(j));
b.A ceiling price that the consultant exceeds at their risk (2 CFR §200.318(j)); and
c. A high degree of oversight that assures consultant is performing work in an efficient
manner with effective cost controls in place 2 CFR §200.318(j)).
Yes No N/A
14. Sponsor is not using or will not use the prohibited cost-plus-percentage-of-cost (CPPC) contract
method. (2 CFR § 200.323(d)).
Yes No N/A
Attach documentation clarifying any above item marked with “no” response.
Sponsor’s Certification
I certify, for the project identified herein, responses to the forgoing items are accurate as marked and
additional documentation for any item marked “no” is correct and complete.
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
Executed on this day of ,.
Name of Sponsor:
Name of Sponsor’s Authorized Official:
Title of Sponsor’s Authorized Official:
Signature of Sponsor’s Authorized Official:
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
City of McCall, Idaho
Robert S. Giles
Mayor, City of McCall
25 March 2021
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-135
U.S. Department
of Transportation
Federal Aviation
Administration
FAA Form 5100-135, Certification and Disclosure Regarding
Potential Conflicts of Interest – Airport Improvement Program
Sponsor Certification
Paperwork Reduction Act Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 2120-0569. Public
reporting for this collection of information is estimated to be approximately 8 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, completing and reviewing the collection of information. All responses to this collection of
information are required under 49 U.S.C. Section 47105 to retain a benefit and to meet the reporting
requirements of 2 CFR 200. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the Federal Aviation
Administration at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
Clearance Officer, ASP-110.
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-135 (/17) SUPERSEDES PREVIOUS EDITION Page 1 of 2
U.S. Department of Transportation
Federal Aviation Administration
OMB CONTROL NUMBER: 2120-0569
EXPIRATION DATE: 8/31/2019
Certification and Disclosure Regarding Potential Conflicts of Interest
Airport Improvement Program Sponsor Certification
Sponsor:
Airport:
Project Number:
Description of Work:
Application
Title 2 CFR § 200.112 and § 1201.112 address Federal Aviation Administration (FAA) requirements for
conflict of interest. As a condition of eligibility under the Airport Improvement Program (AIP), sponsors
must comply with FAA policy on conflict of interest. Such a conflict would arise when any of the following
have a financial or other interest in the firm selected for award:
a) The employee, officer or agent,
b) Any member of his immediate family,
c)His or her partner, or
d) An organization which employs, or is about to employ, any of the above.
Selecting “Yes” represents sponsor or sub-recipient acknowledgement and confirmation of the
certification statement. Selecting “No” represents sponsor or sub-recipient disclosure that it cannot fully
comply with the certification statement. If “No” is selected, provide support information explaining the
negative response as an attachment to this form. This includes whether the sponsor has established
standards for financial interest that are not substantial or unsolicited gifts are of nominal value (2 CFR §
200.318(c)). The term “will” means Sponsor action taken at appropriate time based on the certification
statement focus area, but no later than the end of the project period of performance.
Certification Statements
1. The sponsor or sub-recipient maintains a written standards of conduct governing conflict of
interest and the performance of their employees engaged in the award and administration of
contracts (2 CFR § 200.318(c)). To the extent permitted by state or local law or regulations, such
standards of conduct provide for penalties, sanctions, or other disciplinary actions for violations of
such standards by the sponsor’s and sub-recipient’s officers, employees, or agents, or by
contractors or their agents.
Yes No
City of McCall, Idaho
McCall Municipal Airport
AIP 3-16-0023-030-2021
Construct East-West Taixway (Design Only)
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F
FAA Form 5100-135 (17) SUPERSEDES PREVIOUS EDITION Page 2 of 2
2. The sponsor’s or sub-recipient’s officers, employees or agents have not and will not solicit or
accept gratuities, favors or anything of monetary value from contractors, potential contractors, or
parties to sub-agreements (2 CFR § 200.318(c)).
Yes No
3. The sponsor or sub-recipient certifies that is has disclosed and will disclose to the FAA any
known potential conflict of interest (2 CFR § 1200.112).
Yes No
Attach documentation clarifying any above item marked with “no” response.
Sponsor’s Certification
I certify, for the project identified herein, responses to the forgoing items are accurate as marked and
have the explanation for any item marked “no” is correct and complete.
Executed on this day of , .
Name of Sponsor:
Name of Sponsor’s Authorized Official:
Title of Sponsor’s Authorized Official:
Signature of Sponsor’s Authorized Official:
I declare under penalty of perjury that the foregoing is true and correct. I understand that knowingly and
willfully providing false information to the federal government is a violation of 18 USC § 1001 (False
Statements) and could subject me to fines, imprisonment, or both.
City of McCall, Idaho
Robert S. Giles
Mayor, City of McCall
25 March 2021
DocuSign Envelope ID: 88118A58-7049-4A63-91C1-9BDC5B18269F