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Imp. Proj. #693 PROJECT BULLETIN #1 PROJECT BULLETIN CIVIC CENTER PARK OUTDOOR THEATRE CONCRETE RECONSTRUCTION AND STORM SEWER WORK CITY PROJECT NO. 693 Overview The City of New Hope is replaci~g the stage and seating area at the outdoor theatre in Civic Center Park, 4401 Xylon Avenue North, this fall. The existing concrete and the surrounding asphalt (under the bleachers) has settled over time. This settlement has caused the existing concrete to crack in several areas making it a safety concern, as well as making its maintenance more difficult. The settling can be partially attributed to poor drainage in the area. In order to accomplish this project, the bleachers will be temporarily moved. Once the existing concrete and asphalt are removed, the site will be regraded and drain tile will be installed in the area to improve the drainage situation. The new stage and seating area will be constructed with the same dimensions as the existing area. When the construction is completed, the bleachers will be placed back in their original location. Access to the project area will be from the north end of the City Hall parking lot. Improvements to drainage in this area will include extending storm sewer piping from the free skating area in the park east to the theatre area. Proiect Schedule The New Hope City Council awarded the contract for the replacement of the concrete stage area of the theater in Civic Center Park to Hardrives Inc. at the August 28 Council meeting. At the same meeting they awarded the storm sewer work to Dave Perkins Contracting Inc. Work on the project is expected to begin the week of September 18. The entire project will be completed by the end of October. Construction Hours Construction may occur between the hours of 7:00 a.m. and 9:00 p.m., Monday through Friday, and 9:00 a.m. and 7:00 p.m. on Saturday. All work, including mobilization of equipment, will take place during these time periods. Contact Persons If you have questions or concerns during the concrete replacement project, please direct your calls to the Project Engineer, Vince VanderTop, at (651) 604-4790 or Tom Schuster, Contract Manager, at (763) 533-4823, ext. 13. City of New Hope 4401 Xylon Avenue North New Hope, MN 55428 Phone: 531-5100 Sept. 18. 2000 Projects\693\Project Bulletin#1.doc COUNCIL REQUEST FOR ACTION Originating Department Approved for Agenda Agenda Section Parks & Recreation August 28, 2000 Consent Item No. By: Shari French By: 6.5 APPROVAL OF QUOTE SUBMITTED BY: ARDDRIVES FOR THE CIVIC CENTER PARK OUTDOOR THEATRE CONCRETE REPLACEMEN~ PROJECT #693 AND AUTHORIZATION TO PURCHASE - $46,755.00 REQUESTED ACTION Staff is recommending that the Council approve the low quote received for concrete and asphalt work to be done this fall at the Outdoor Theatre in Civic Center Park. The low quote is from Harddrives and totals $46,755.00. This work needs to be done in the fall as the facility is needed beginning May 1 st by the production company hired to put on the summer family musical each year (Off Broadway Musical Theatre). Any work done in the spring would not be completed by this early spring date. Concrete work budgeted to be done this fall at the Fire Station was bid as an alternate to this project. The bid from Harddrives totals $6,128.75. Staff recommends that this alternate not be accepted and that the work be rebid in the spring. This work can be done basically any time of the year during appropriate weather. BACKGROUND The outdoor theatre was built in 1987. The concrete and asphalt are both in need of replacement due to age but also due to poor drainage in the immediate area. FUNDING The 2000 Park CIP contains $32,000 for this project. Staff recommends that $14,755 of the $73,326 carried over from 1999 CI P designated for trail work be used for this project. Final cost should assume an additional approximately 200/0 in engineering. Quotes were sought from four vendors; received from three, and those are summarized below. . Harddrives - $46,755.00 . Midwest - $46,922.50 . DMJ - $47,705.25 MOTION BY fi1 (...__,.,~?f{:",":)<2",l'",/)"'j ../ SECOND BY TO: I:RFA\P&R\Parks\Q-Quotes Theatre Concrete 693.doc Bonestroo Rosene Anderlil< & Associates Bonestroo, Rosene, Anderlik and Associates, Inc. is an Affirmative Action/Equal Opportunity Employer and Employee Owned Principals: Otto Bonestroo, P .E. .. Marvin L. Sorvala, P .E. .. Glenn R. Cook, P .E. .. Robert G. Schunicht, P .E. .. Jerry A. Bourdon, P .E. Senior Consultants: Robert W. Rosene, P .E. .. Joseph C. Anderlik, P .E. .. Richard E. Turner, P .E. .. Susan M. Eberlin, C.P .A. Associate Principals: Howard A. Sanford, P. E. .. Keith A. Gordon, P. E. .. Robe rt R. Pfeffer! e, P. E. · Richard W. Foster, P .E. .. David O. Loskota, P .E. . Robert C. Russek, A.LA. .. Mark A. Hanson, P .E. .. Michael T. Rautmann, P.E. .. Ted K. Reid, P.E... Kenneth P. Anderson, P.E. . Mark R. Rolfs, P.E. · David A. 80nestroo, M.B.A. . Sidney P. Williamson, P.E., L.S. . Agnes M. Ring, M.B.A., . Allan Rick Schmidt, P .E. Offices: St. Paul, Rochester, Willmar and S1. Cloud, MN . Milwaukee, WI Website: www.bonestroo.com Engineers & Architects MEMO To: From: Date: Re: Shari French Vince Vander Top August 22, 2000 Civic Center Park Theater Concrete Reconstruction Project # 693 BRAA 34-00-124 We have received quotes to reconstruct the concrete and bituminous around the outdoor theater at Civic Center Park. The concrete has cracked and settled. The bituminous is rutted and in poor condition. The improvements would include: II Constructing storm sewer and drain tile to improve surrace and sub grade drainage Reconstruct the concrete to existing dimensions Reconstruct the bituminous to existing dimensions D . We have met with theater production company and have reviewed the improvements with them. They are in agreement with scope of the project. The project also includes the replacement of some cracked sidewalk and pedestrian ramps by City Hall and the parking lot. It is efficient to do this concrete work in conjunction \vith the theater. Four quotes were requested and three were received. The quotes included an alternate to remove and replace some concrete behind the fire station. The quotes were as follows: Harddrives DMJ Corp. Midwest Ashpalt North Valley Paving Base Bid $46,755.00 $47,705.25 $46,922.50 Bid not submitted Alternate (Fire Station) $6,128.75 $5,983.00 $7,749.00 Total $52,883.75 $53,688.25 $54,671.50 Engineer's Estimate $43,780.00 $5,336.25 $49,116.25 The Engineer's Estimate is comparable to the low bid. The bituminous price is approximately $2,000 higher than the estimate accounting for most of the difference. The bid unit prices for bituminous reflect the small area of work and the amount of hand work required. Overall, the bids are favorable. We recommend the award of the Io\v bid to Harddrives. We do not, however, recommend the award of the alternate including the concrete replacement at the fire station. Although the prices are favorable, \ve are required to limit the contract to $50,000 or lower because the project was not advertised. Quotes \vere solicited. The fire station work will have to be added to another project next spring. We will also be receiving separate quotes from utility contractors for the installation of the storm sewer. We anticipate these quotes will be on the order of $8,500.00. Approval of these quotes should be considered at the saIne time as the quotes listed above. 2335 West Highway 36. St. PEiul; MN 55113. 651-636-4600 · Fax: 651-636-1311 GORDON L. JENSEN* STEVEN A. SONDRALL MARTIN P. MALECHA WILLIAM C. STRAITt C. ALDEN PEARSONt JULIE A. THILL OF COUNSEL LORENS Q. BRYNESTAD *Real Property Law Specialist Certified By The }"'linnesota State Bar Association tQunlified ADR Neutral JENSEN & SONDRALL, P.A. Attorlleys At Law 8525 EDINBROOK CROSSING, STE. 201 BROOKL YN P ARK, MINNESOTA 55443-1968 TELEPHONE (763) 424-8811 . TELEFAX (763) 493-5193 e-mail la\v@jensen-sondrall.com September 21, 2000 Valerie Leone City of New Hope 4401 Xylon Avenue North New Hope, MN 55428 RE: Civic Center Park Theatre Concrete Reconstruction Our File No. 99.10030 Dear Valerie: Enclosed please find three copies of the contracts and bonds for the above-referenced project, as well as a fax copy of the Certificate of Insurance. All are in order from a legal standpoint. You should be receiving the original of the Certi:Qcate of Insurance by mail. If you have not received it within the next few weeks, plea^s~ contact me. \ \ ,-)t Be sure to call if you have any questions. ~GcLi v Sincerely, I~A~!1~ " ~1f[;IV / r"JJj1~ Martin P. Malecha Assistant City Attorney cc: Daniel J. Donahue, City Manager Kirk McDonald, Director of Community Development Shari French, Director of Parks and Recreation Vince Vander Top, Assistant City Engineer Steven A. Sandrall, City Attorney ~~{ A." COR :::::............................g~I:III~~lllm"*::lli~11:~:II_::::::I:I~I::lllli:::::::::::PAGi::::::,::::Qig 2D1~~~~~f~S6 .. '"p'FiODlJCER''' ........... .... ... ........... .......... .............--...---..--....... --... ..-_... .---....--....34S.4fi.. ........... THIS CERTIFICATE IS ISSUED AS A MA TIER OF INFORMATION Willis North America, Inc. - RegionalCert Center ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 11201 N. Tatum Blvd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Suite 300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phoenix AZ 85028 COMPANIES AFFORDING COVERAGE (877) 559-6769 20478.{J02 (MINN) COMPANY National Fire Insurance Company of Hartford A 20494-001 (MINN) COMPANY Transportation Insurance Company B 20486-001 (MINN) COMPANY Transcontinental Insurance Company C INSURED HARDRIVES, INC. 14475 QUIRAM DRIVE ROGERS MN 55374 I COMPANY o 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 CERTIFICA.TE 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. CO; I ~ I , . i POLICY EFFECTIVE i POLICY EXPIRATION! i DATE. (r.1MjDD[YY) i DATE {MMfDDfYY) LIMITS LTR TYPE OF INSURANCE POLICY NUMBER I A~NERALLlABILlTY I!GL 162775310 i X ! COMMERCIAL GENERAL LIABILITY , L......II CLAIMS MADE ~ OCCUR i 1 I OW'NER'S & CONTRACTOR'S PROT 1 01-JAN-2000 01-JAN-2001 I GENERAL AGGREGATE 1$ i PRODUCTS.cOMP/OP AGG i $ 'PERSONAL& ADV INJURY ! EACH OCCURRENCE FIRE DAMAGE (Anyone fire] B ~OMOBILE LIABILITY ! Xi ANY AUTO I i ~ ALL OWNED AUTOS ~ SCHEDULED AUTOS i X i HIRED AUTOS \Xl NON-GWNED AUTOS ! i n iBUA 162775288 01-JAN-2000 01-JAN-2001 ! COMBINED SINGLE LIMIT t I BODILY INJURY i (Per person) i I BOD1L Y INJURY ! (Per accident) PROPERTY DAMAGE ,"~~~AGE LIABILITY ANY AUTO i AUTO ONLY. EA ACCIDENT i $ i OTHER THAN AUTO ONLY: ~ EACH ACCIDENT t $ AGGREGATE 1$ j ~ ! EACH OCCURRENCE is ,AGGREGATE ,$ B ...,~)(~ESS LIABILITY , X "~)Vi5REL~A rORM IL 162775307 01-JAN-2001 o 1-JAN-2000 QTHER THt'\r-~ U~ABRELU\ FORM $ ! OTH.; lER ; 1$ C WORKERS COMPENSATION AND we 162775291 EMPLOYERS'L1ABILlTY I THE PROPRIETOR! R I PARTNERS/EXECUTIVE INCL I OFFICERS ARE: EXCU 01-JAN-2000 01-JAN-2001 i Xi~gR~l~1~TS i i EL EACH ACCIDENT i EL D1SEASE~POLlCY LIMIT 1 $ EL DISEASE-EA EMPLOYEE ! $ DESCRIPTION OF OPERA TIONSfLOCA TIONSjVEHICLESfSPECIAL ITEMS SEE ATTACHED \$ I is 2,000,000 2,000,000 1,000,000 1,000,000 100,000 10,000 1,000,000 is j is i is I I ]$ I is I 10,000,000 10,000,000 100,000 500,000 100,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~~)t~ MAIL CITY OF NEW HOPE 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEF"fJ A TTN : VALERI E LE 0 NE ~ 1tXK_1Ut~"YG( >tYAlt{ >SUCH< N~Itc1:XSE(.l(1flX lt~ Xf()X0Bl{~lON<:om KrA:8lJ.lIU X X 4401 XYLON AVENUE NO. cmX)Ut:tX~N~ ~X~~lXX~~X~XJ((;'Hf~Xl>~X~~~XX ...........J~EWHOPE MN 55428 A~A W II ~~~~~r~i~.~i5jm~T*:I:\iB~:I;::~~~~A~~Ti5~~i~~~IS~Elrl;\i!~i~ii~jl}1i~Dj~~A~~~kl.if:r~rtrfrrfffr{Irrfnfr(~~r~rfrrfr~~frfj~r ISS U E DATE (MMjOO/Yy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE I HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 34548 INSURED HARDRIVES, INC. 14475 QUIRAM DRIVE ROGERS MN 55374 PRODUCER Willis North America, Inc. - Regional Cert Center 11201 N. Tatum Blvd. Suite 300 Phoenix AZ 85028 (877) 559-6769 I THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLlCY 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. I I POLICY EFFECTIVE I POLICY EXPIRATION I TYPE OF INSURANCE POLICY NUMBER I DATE (MM/DD/YY) DATE (MM/OOryy) i LIMITS DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Re: Civic Center Park Theater - Job#: 62690, BRA File#: 34-00-124 City of New Hope is included as Additional Insured under the General Liability policy as respects work performed by the Named Insured. This coverage is Primary SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~~>t~ MAIL CITY OF NEW HOPE ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,. ATIN: VALERIE LEONE ~~AW,.XIl1l!X"RCX~t(~tU~X~St:(~I:4);~ll:OX(ll2t(~)QN(~)(~nxx 4401 XYLON AVENUE NO. o:F.<~X~IJQ !inSX:A'Gf::fNSX:oR<~fJJiAlI)1E$XXXXXX NEW HOPE MN 55428 2UTHO D~p/ESENTATIVE ,.- , -/&.- -~ CITY OF NEW HOPE CONTRACT FOR CIVIC CENTER PARK THEATRE CONCRETE RECONSTRUCTION .oc .A \ ,Jl ~. . sy}:~:5.f) For valuable consideration as set forth below, this contract dated the 6th day of e. ber, 2600. is made and signed by the City of New Hope (hereinafter "City") and Hardrives, Incorporated. (hereinafter "Contractor") . 1. CONTRACT DOCUMENTS The Contractor hereby promises and agrees to perform and comply with all the provisions of this Contract and specifications. all of which are incorporated hereby by this reference. This Contract shall compromise the total agreement of the parties hereto. No oral order, objection or claim by any party to the other shall affect or modify any of the terms or obligations contained in this Contract. 2. THE WORK The work to be performed by Contractor under this Contract (hereinafter the "Wark"), is defined in Exhibit A (request for proposal). Any modifications to the work defined in Exhibit A will be made in writing. 3. CONTRACT PRICE The City agrees to pay the contractor $46.755 dollars, payable in accordance with the payment terms of the City of New Hope Instruction to Bidders. Contractor will be charged liquidated damages assessed in the amount of $100 per day for every calendar day that the contract remains uncompleted beyond the 31 st day of October, 2000. Total amount of this contract shail not exceed $46,755 dollars. 4. COMPLETION DATE Contractor shall complete his performance under this Contract by the 31 st day of October, 2000 (hereinafter uCompletion Daten). 5. INSURANCE/BOND Before beginning actual work under this Contract. the Contractor shall submit to the City and obtain the City's approval of a certificate of insurance on Standard Form C.I.C.C.-701 or ACORD 25 forms, showing the following insurance coverage and listing the City as a loss payee under the policies: b. Automobile Liability for all Automobiles: $1,000,000.00 $1 ,000,000.00 a. General Contractor Liability: c. Workman's Compensation: Statutory Amounts 504-Gen Basic Contract Contract Page 2 This certificate must provide for the above coverages to be in effect from the date of the Contract until 30 days after the Completion Date and must provide the insurance coverage will not be canceled by the insurance company without 30 days written notice to the City of intent to cancel. The certificate must further provide that the contractor's insurance coverage is primary coverage notwithstanding any insurance coverage carried by the City that may apply to injury or damage relating to the maintenance or repair of the City's streets or right-af-ways by either the City or any employee, agent, independent contractor or any other person or entity retained by the City to perform the services described herein. This certificate must further provide that the Contractor's insurance coverage is primary coverage notwithstanding any insurance coverage carried by the City that may apply to injury or damage relating to the maintenance or repair of the City's streets or rightooof-ways by either the City or any employee, agent, independent contractor, or any other person or entity retained by the City to perform the services described herein. The Contractor shall furnish Performance and Materials/Labor Bonds, each in an amount at least equal to the Contract Price as security for the faithful performance and payment of all Contractor's obligations under the Contract Documents. These Sands shall remain in effect at least until one year after the date of final payment, except as otherNise provided by law. All Bonds shall be in the forms prescribed by the Contract Documents and be executed by such Sureties as (A) are licensed to conduct business in the State of Minnesota, and (8) are named in the current list of "Companies Holding certificates of Authority as Acceptable Sureties on Federal Bonds and as Acceptable Reinsuring Companies" as published in Circular 570 (amended) by the Audit Staff Bureau of Accounts, U.S. Treasury Department. All bonds signed by an agent must be accompanied by a certified copy of the authority to act. If the Surety on any Bond furnished by Contractor is declared bankrupt or becomes insolvent or its right to do business is terminated in the State of Minnesota or it ceases to meet the requirement of clauses (A) or (8) in the previous paragraph, Contractor shall within five days thereafter substitute another Bond and Surety, both of which shall be acceptable to City. All bonds and insurance are subject to the review and approval of the New Hope City Attorney. 6. LAWS. REGULATIONS AND SAFETY The Contractor shall give all notices and comply with all laws, ordinances, rules and regulations applicable to performance under this Contract. 7. INDEMNIFICATION The Contractor agrees to indemnify, defend and hold the City harmless from any damages, including costs and attorney's fees, from any claims, demands, actions or causes of action arising out of any act or omission on the part of the Contractor or its agents, servants or employees in the performance of or with relation to any of the work or services performed or furnished by the contractor under this Contract. 8. ASSIGNMENT The Contractor shall not assign or transfer, whether by an assignment or notation or otherwise, any of its rights, duties, benefits, obligations, liabilities or responsibilities without prior written consent of the City. 34-Gen-Basic Contract Contract Page 3 9. NOTICE The address and telephone number of the Contractor for purposes of giving notices and any other purpose under this contract shall be 14475 Quiram Drive~ Roaers. MN 55374. (763-428-8886) The address of the City for purposes of giving notices and any other purpose under this contract shall be 4401 Xylon Avenue North, New Hope, MN 55428. The contact person for this contract is Valerie Leone. IN WITNESS WHEREOF, the parties to this Contract have hereunto set their hands and seals as of the day and year first above written. CITY OF NEW HOPE ~"/""'/~ 1'" ,/ ..' re-'" ~-,.----....... .................... ". ,,/ ~ ..l.l/ .' .....? . ~ c.. "'/'/..' B"'''''... .~. .','..-' ~./'" /,'~' >;:/. .... . .... ?~;/ . .,/~ / ( J../"j' ... · ./ --."", \.: ~/ ~ ...~ay6r P:ntru'Yl __ /~./) '. U A"'/ 111 1:./:"/ 7 ii' I / iI/ . .//: By / 'L/i!/f/tiA-..e.f .'. . k, ./Lo"1 /j?!-._g::~..L--I Ats CIManage'r /F - CONTRACTOR By Its Representative steven K. Hall, President 34..Gen..8asic Contract Contract Page 4 STATE OF MINNESOTA COUNTY OF HENNEPIN ) ) 55. ) "'1 i T\ 1;..1 - /J .+t.ryv L.){t/LClJL/.Lw "7 - / TO I ,;(he foregoing was acknowledged before ,me this t:7\ ..:) day of cJ..evfe~ , 2000, byW. Pater [ncK and Daniel J. Donahue, the Mayor~nd City Manager,' respectively, of the City of New Hope, a Minnesota municipal corporation, on behalf of said municipal corporation. ~.....~~~~~~~~f?.,..,.~ o ~ TWt Cl) .~ .'; ..,"i:-.'\ VALERIE J. LEONE (:.1 y:': :\~;;~J1~'-'. NOTARY PUBLIC-MINNESOTA .~~ .c.::;.~ "'$~:~~'\" My Commission Expires Jan. 31, 2005 8~ ,'i:':b'2~~:?Z='~~~~~ i71hLU ~dh0 Notary Public / STATE OF MINNESOTA COUNTY OF HENNEPIN ) ) 58. ) The foregoing was acknowledged before me on this 11 th SeptemlY:?r , 2000, by ~t-~\lPn K H~ 11 of HMrnri \TA~ f Tnc: of Djrector<3 day of , on behalf of It's Board ELAINE R. WICK NOTARY PUBLIC.. fv11NNESOTA HENNEPIN COUNTY Expires Jan. 31, 2005 34-Gen-Basic Contract .THE AMERICAN INSTITUTE OF ARCHITECTS Bond No. 81631261 AlA Document A311 Performance Bond KNOW All MEN BY THESE PRESENTS: that HARDRIVES, INC. (Here insert full name and address or legal title of Contractor) 14475 QUIRAM DRIVE ROGERS, MN 55374 as Principal, hereinafter called Contractor, and, Federal InsuI:ance Company 15 Mountain View Road (Here insert full name and address or legal title of Surety) WarI:en, NJ 07059 as Surety, hereinafter called Surety, are held and firmly bound unto City of New Hope New Hope, MN (Here insert full name and address or legal title of Owner) as Obligee, hereinafter called Owner, in the amount of Forty-Six Thousand Seven-Hundred Fifty-Five and 00/100 ---- Dollars ($46,755 . 00 ) , for the payment whereof Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, Contractor has by written agreement dated September 6 Civic Center Park TheatI:e ConcIete ReconstIuction New Hope, MN 2000 , entered into a contract with Owner for in accordance with Drawings and Specifications prepared by (Here insert full name and address or legal title of Architect) BonestIoo, Rosene, Anderlik and Associates, Inc. 2335 West Highway 36, St. Paul, MN 55113 which contract is by reference made a part hereof, and is hereinafter referred to as the Contract. WCA.1219A · PERFORMANCE BOND AND LABOR AND MATERIAL PAYMENT BOND. AlA @ FEBRUARY 1970 ED. THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 N.Y. AVE., N.W., WASHINGTON, D.C. 20006 1 NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION is such that, if Contractor shall promptly and faithfully perform said Contract, then this obligation shall be null and void; otherwise it shall remain in full force and effect The Surety hereby waives notice of any alteration or extension of time made by the Owner. Whenever Contractor shall be, and declared by Owner to be in default under the Contract, the Owner having performed Owner's obligations thereunder, the Surety may promptly remedy the default, or shall promptly 1) Complete the Contract in accordance with its terms and conditions, or 2) Obtain a bid or bids for completing the Contract in accordance with its terms and conditions, and upon determination by Surety of the lowest responsible bidder, or, if the Owner elects, upon determination by the Owner and the Surety jointly of the lowest responsible bidder, arrange for a contract between such bidder and Owner, and make available as Work progresses (even though there should be a default or a succession of defaults under the contract or contracts of Signed and sealed this day of 20th hi , //["7 .'~ f.-, / ~ < , .\// (. i / / A J il J ./ / ~il?ttLV - I (Witness) \~~."" X~ r ./ r (fA4U. /I---- // (Witness) completion arranged under this paragraph) sufficient funds to pay the cost of completion less the balance of the contract price; but not exceeding, including other costs and damages for which the Surety may be liable hereunder, the amount set forth in the first paragraph hereof. The term "balance of the contract price," as used in this paragraph, shall mean the total amount payable by Owner to Contractor under the Contract and any amendments thereto, less the amount properly paid by Owner to Contractor. Any suit under this bond must be instituted before the expiration of two (2) years from the date on which final payment under the Contract falls due. No right of action shall accrue on this bond to or for the use of any person or corporation other than the Owner named herein or the heirs, executors, administrators or successors of the Owner. September, 2000 (Seal) (litle) Presiden~ Federal Insurance Company (Surety) (Seal) /) v"~[/~'l /'~'A::)(:/(,- (Title) At torney - in" Fact VSwanson WCA~1219B · PERFORMANCE BOND AND LABOR AND MATERIAL PAYMENT BOND' AlA @ FEBRUARY 1970 ED. · THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 N.Y. AVE., N.W., WASHINGTON, D.C. 20006 2 THE AMERICAN INSTITUTE OF ARCHITECTS Bond No. 81631261 AlA Document A311 Labor and Material Payment Bond THIS BOND IS ISSUED SIMULTANEOUSLY WITH PERFORMANCE BOND IN FAVOR OF THE OWNER CONDITIONED ON THE FULLAND FAITHFUL PERFORMANCE OFTHE CONTRACT KNOW All MEN BY THESE PRESENTS: that HARDRIVES, INC. 14475 QUIRAM DRIVE ROGERS, MN 55374 as Principal, hereinafter called Principal, and, 15 Mountain View Road (Here insert full name and address or legal title of Contractor) FedeIal InSUIance Company (Here insert full name and address or legal title of Surety) Wa~xen, NJ 07059 as Surety, hereinafter called Surety, are held and firmly bound unto City of New Hope New Hope, MN (Here insert full name and address or legal title of Owner) as Obligee, hereinafter called Owner, for the use and benefit of claimants as hereinbelow defined, in the amountof Forty-Six Thousand Seven-Hundred Fifty-Five and 00/100 (Here insert a sum equal to at least one~half of the contract price) Doll a rs ($ 4 6 , 75 5 . 0 0 ) , for the payment whereof Principal and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, Principal has by written agreement dated septembe:r 6, 2000 Civic Cente:r Park Theatre Concrete ReconstIuction New Hope, MN , entered into a contract with Owner for in accordance with Drawings and Specifications prepared by (Here insert full name and address or legal title of Architect) Bonest:roo, Rosene, Ande:rlik and Associates, Inc. 2335 West Highway 36, St. Paul, MN 55113 which contract is by reference made a part hereof, and is hereinafter referred to as the Contract. WCA..1220A · PERFORMANCE BOND AND LABOR AND MATERIAL PAYMENT BOND · AlA @ FEBRUARY 1970 ED. · THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 N.Y. AVE., N.W., WASHINGTON, D.C. 20006 3 NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION is such that if Principal shall promptly make payment to all claimants as hereinafter defined, for all labor and material used or reasonably required for use in the performance of the Contract, then this obligation shall be void; otherwise it shall remain in full force and effect, subject, however, to the following conditions: 1. A claimant is defined as one having a direct contract with the Principal or with a Subcontractor of the Principal for labor, material, or both, used or reasonably required for use in the performance of the Contract labor and material being construed to include that part of water, gas, power, light, heat, oil, gasoline, telephone service or rental of equipment directly applicable to the Contract. 2. The above named Principal and Surety hereby jointly and severally agree with the Owner that every claimant as herein defined, who has not been paid in full before the expiration of a period of ninety (90) days after the date on which the last of such claimant's work or labor was done or performed, or materials were furnished by such claimant, may sue on this bond for the use of such claimant, prosecute the suit to final judgment for such sum or sums as may be justly due claimant and have execution thereon. The Owner shall not be liable for the payment of any costs or expenses of any such suit 3. No suit or action shall be commenced hereunder by any claimant: a) Unless claimant, other than one having a direct contract with the Principal, shall have given written notice to any two of the following: the Principal, the Owner, or the Surety above named, within ninety (90) days after such claimant did or performed the last of the work or labor, or furnished the last of the materials for which said claim is made, stating with substantial accuracy the amount claimed and the name of the party to whom the materials were furnished, or for whom the Signed and sealed this day of 20th J/ \~/?.c /7 j~{ ,/Z..) ,,/ / ,~1.. M (,.(.1j,-~ (Wi ness) //"1 ./ ,'/ \v~/~' i"j /f " ,It"- ,'-- /1 ./" /' ~// \ '(.../'f / / /' ./ - (/~~ j'(WitneSS) work or labor was done or performed. Such notice shall be served by mailing the same by registered mail or certified mail; postage prepaid, in an envelope addressed to the Principal, Owner or Surety, at any place where an office is regularly maintained for the transaction of business, or served in any manner in which legal process may be served in the state in which the aforesaid project is located, save that such service need not be made by a public officer. b) After the expiration of one (1) year following the date on which Principal ceased Work on said Contract, it being understood, however, that if any limitation embodied in this bond is prohibited by any law controlling the construction hereof such limitation shall be deemed to be amended so as to be equal to the minimum period of limitation permitted by such law. c) Other than in a state court of competent jurisdiction in and for the county or other political subdivision of the state in which the Project, or any part thereof, is situated, or in the United States District Court for the district in which the Project, or any part thereof, is situated, and not elsewhere. 4. The amount of this bond shall be reduced by and to the extent of any payment or payments made in good faith hereunder, inclusive of the payment by Surety of mechanics' liens which may be filed of record against said improvement, whether or not claim for the amount of such lien be presented under and against this bond. September, 2000 (Seal) Steven K. Hall (Title) President Federal Insurance Company (Surety) (Seal) /-\ /'! . i' Ii Jill N. s~anson (Title) Attorney-in-Fact WCA.1220B · PERFORMANCE BOND AND LABOR AND MATERIAL PAYMENT BOND. AlA @ FEBRUARY 1970 ED. · THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 N,Y. AVE" N,W., WASHINGTON, D.C, 20006 4 ~Chubb ~ Surety POWER OF ATTORNEY Federal Insurance Company Vigilant Insurance Company Pacific Indemnity Company Attn..: Surety Department 15 Mountain View Road Warren, NJ 07059 Know All by These Presents. That FEDERAl.. INSURANCE COMPANY, an Irxfiana ~I. VlGILANT INSURANCE COMPANY, a New YOfk corporation. and PACIFIC lNOEMNfTY COMPA.'lY. a Wisconsin corporation. do each hereby constitute and appoint Jill N.. Swanson, Laurie Pflug, Dennis G.. Loots, Jerry Ouimet and B..L.. Kellar of Minneapolis, Minnesota--- each as their true and lawful Attomey~n-Fad to execute under such designation fn their names and to affIX their corporate seats to and derIVer for and on their behalf as surety thereon or otherwise. bonds (other than bail bonds) and undertakings given or executed in the course of its business (but not to indude any instruments amending or attering the same, nor consents to the modifICation or alteration of any instrument referred to In said bonds or obligations) . In Witness Whereof. said FEDERAL INSURANCE COMPNfY. VIGILANT fNSUR..M\CE COMPANY, and PACIFIC INDEMNITY COMPANY have each executed and attested these presents and affIXed their corporate seals on this 8 t h day of J un e 1999 fhe~~~~~ STATE OF NEW JERSEY} I&. County of SOInef'IeI On this 18 t h day 0( J un e, 1 9 9 9 before me, a Notary PubUc or Nevi Jersey, personally came Sheryt B.Roberts. to me known to be Assistant Secretary of FEDeRAl.. INSURANCE CCNi'AHY, VIGIlANT INSURANCE CCMPANY. and PAClFIC INDEMNITY calFNff. the companies which executed the rexeg04ng ?ONef cI A:10lTlt!')'. and the said Sheryf B. Roberts being by me duty S'NOm. cftd depose and say that she is As:sistard Secretary or FEDERAL INSURANCE COMPPJiY, 'IlGn.ANT INSURANCE CCMPNlY. and PACIFlC INDEMNITY CQMPAHY and k:ncws the corponate seats theteor, t~t the .eals affIXed to the focegcing PONer ol A.-.omey are such COC"pOf'2te seals and were thereto affIXed by authority o( the By.l.aY.-s d said Companies: and that she signed a.aid PcPNerof An~ as Assistant Se<:.retary of said Companies by like authority; arxf that she is acquainted with Frank E. Robertson, and knoNs him to ge Va Pre'Sidem of said Companies; and that \:he signature of Frank E. Robertson. 'SUbscribed to &aid Power or Attorney is in the genuine h.an<:tNriting of Frank E. Robertson, and was thereto wbs.etibed by authority 01 said By.l.aY.-s and in deponents presence. THE:RESA 8. CICHOWSKI Notary Public, St.&lte of New Jersey No. 0014101 Cornn; is.sJon Expf res J\J[Y 27. 200 1 ~ day of Septernber~ 2000 JlLu/te~~~~ IN THE EVENT YOU WISH TO NOTIFY US OF A CLAIM, VERIFY THE AUTHENTICITY OF THIS BOND OR NOTIFY US OF ANY OTHER MATTER, PLEASE CONTACT US AT ADDRESS LISTED ABOVE, OR BY Telephone (908) 903-3485 Fax.- .(908)903-3656 e-mail: surety@chubb.com Fcnn 1 $.. 1 Q.0228 A (Ed. ~ NC>N-COHSCNT 4401 Xylon Avenue North New Hope. Minnesota 55428-4898 www.ci. ne w~hope. m n. us City Hall: 763-531-5100 Police: 763-531-5170 Public Works: 763~533-4823 TOO: 763-531-5109 City Hall Fax: 763-53 i -513f Police Fax: 763-53i -5 7 7~ Public Works Fax: 763-533- 7650 October 3, 2000 Mr. Steven Hall Hardrives, Inc. 14475 Quiram Drive Rogers, MN 55374 Subject: Civic Center Park Outdoor Theatre Concete Replacment - Project No. 693 Enclosed is a fully executed contract for the fore-mentioned project. The New Hope City Council awarded this contract for $46,755 to your company on August 28, 2000. Thank you for performing this work. Also enclosed is an IC-134 form (Withholding Affidavit for Contractors). The City cannot make final payment to contractors until this is approved by the Minnesota Department of Revenue and submitted to our office (Minnesota Statute 290.97):_:The form contains instructions for completion. Sincerely, t.fic7U- Valerie Leone, CMC City Clerk Ene. cc: Shari French, Director of Parks and Recreation Vince Vander Top, BRAA Tom Schuster, Contract Manager Family Styled CitY~~Ji1\n. ,.,rr1l~J For Family Living v ~..: '.~ ,I'~ 'l~ COUNCIL hi7P 6 '73 ~m ~ HO REQUEST FOR ACTION Originating Department Approved for Agenda Agenda Section Parks & Recreation Consent November 13, 2001 ,",'" By: )) / MOTION TO ACCEPT IMPROVEMENT PROJECT NO. 693 (CIVIC CENTER PARK OUTDOOR THEATRE CONCRETE REPLACEMENT PROJECT) TO HARDDRIVES INC. AND APPROVE FINAL PAY REQUEST IN THE AMOUNT OF $2,449.73 Item No. By: Shari French 6.5 REQUESTED ACTION Staff is recommending that the Council accept Improvement Project 693 and approve final payment to Hardrives Inc. in the amount of $2,449.73. The City will issue final payment when all appropriate paperwork has been received from the contractor to close out this project. BACKGROUND This project involved replacing the concrete and asphalt at the theatre due to age but also due to poor drainage in the immediate area. FUNDING The cost of this project totals $49,365.16 or $2,610.15 (5.60/0) over the original contract amount of $46,755. The additional costs were mainly the results of poor sub grade materials encountered during the construction. The contractor also sprayed the concrete curing compound on the bottom block courses of the theatre during the replacement of the concrete. The block was repainted by a different contractor at a cost of $740.00 and that cost was deducted from the final payment. Funding came from 2000 Parks CIP. ATTACHMENTS The EngineerJs letter recommending final payment is attached. MOTION BY i:tr ~J-Ul ,-/J{]/y/;;t:JL - ,/ SECOND /'" BY ( !j!LJap ~/l- TO: 60vCUJf jI I:RFA\P&R\Parks\final 679 Theatre Concrete.doc Bonestroo Rosene Anderlil< & aSsociates Bonestroo, Rosene, Anderlil< and Associates, Inc. is an Affirmative Action/Equal Opportunity Employer and Employee Owned Principals: Otto G. Bonestfoo, FE. ., i'viarvin L. SarI/ala, RE. · Glenn R. Cook. PE. · Raben G. $chunicht, r.E. · Jerry A. Bourdon. RE. Engineers & Architects Senior Consultants: Roben VI. Rosene, P.E. · Joseph C. AnderlJk, P.E. · Richard E. Turner, P.E. . Susan M. Eberlin. C.P.A. Associate Principals: Keith A. Gordon. RE. . Robert R. Pfefferle, PE. · Richard W. Foster, RE. .. David O. Loskota, P.E. .. Mark A. Hanson. RE. .. Michael T. RaUL/llann, P.E. .. Ted K. Field. RE. · Kennerll P. Anderson, PE. ,. Mark R. Rolfs, PE. · David A. 80nest,oo, iv1.B.i"". " Sidney P. V/illiamson, RE., L.S. " Agnes M. Ring, M.B.A. · Allan Rick Schmidt. PE. " Thomas \V. Peterson, PE. " James R. Maland. PE. .. :'v1il125 B. Jensen, PE. · L. Phillip Gravel 111. PE. " Daniel J. Edgerton. RE. " Ismael Martinez. PE. · Thomas A. Syfko, PE. · Sheldon J. Joilnson " Dale A. Grove, PE." Thomas A. RoushaL PE. " Raben J. Del/ery. RE. o ffi ce 5: S t. P au/. S t. C loud. Ro Ctle ster an d V/ilJm ar, :/11'1 " t/1i1\vaukee. Vi! " Chicago. !L Website: v/v'/w.bonesrroo.com November 5,2001 Shari French City of New Hope 4401 Xylon Ave. New Hope, MN 55428-4898 Re: Civic Center Theater Concrete Reconstruction City of New Hope Our File No. 34-00-124 City Project #693 Dear Shari: Enclosed find the final pay request and IC-134 forms for the New Hope Theater Concrete Reconstruction. The final value of the construction is $49,365.16 or $2,610.16 (5.6%) over the original contract amount of $46,755.00. The additional costs were mainly the result of poor subgrade materials encountered during the construction. The contractor also sprayed concrete curing compound on the bottom block courses of the theater during placement of the concrete. The block was repainted at a cost of $740.00. This cost was deducted from the final payment. All work is completed. We recommend final payment in the amount of $2,449.73. Please contact me if you have questions. Very truly yours, BONESTROO, ROSENE, ANDERLIK & ASSOCIATES, mc. ~~~ Vincent T. Vander Top Enclosures 2335 West Highway 36 .0 St. Paul, MN 55113;] 651-636-4600n Fax: 651-636-1311 . a Bonestroo I[:JI Rosene 1\1 Anderlik & l~l Associates Engineers & Architects For Period: 11/29/2000 to 8/29/2001 Contractor: Hardrives Inc., 14475 Quiram Dr., Ro ers, MN 55374 Date: Re uest No: Au ust 29, 2001 2 AND FINAL CONTRACTOR'S REQUEST FOR PAYMENT CIVIC CENTER PARK THEATER CONCRETE RECONSTUCTION BRA FILE NO. 34-00-124 SUMMARY Original Contract Amount $ 46,755.00 2 Change Order - Addition $ 0.00 3 Change Order - Deduction $ 0.00 4 Revised Contract Amount $ 46,755.00 5 Value Completed to Date $ 49,365.16 6 Material on Hand $ 0.00 7 Amount Eamed $ 49,365.16 8 Less Retainage 00/0 $ 0.00 9 Subtotal $ 49,365.16 10 Less Amount Paid Previously $ 46,915.43 11 Liquidated damages - $ 0.00 12 AMOUNT DUE THIS REQUEST FOR PAYMENT NO. 2 AND FINAL $ 2.449.73 Recommended for Approval by: BONESTROO, ROSENE, ANDERLIK & ASSOCIATES, INC. ~~~~ Approved by Contractor: HARDRIVES IN. C ~.O ~~\) . " Approved by Owner: CITY OF NEW HOPE ~ Specified Contract Completion Date: June 15, 2000 Date: 1/ /i ," C / - Xl- ) / 3400124REQ2Final.xls Contract Unit Quantity Amount No. Item Unit Quantity Price to Date to Date Part 1 .. Base Bid 1 Remove bituminous pavement Sy 525 2.50 525 $1,312.50 2 Remove concrete pavement Sy 275 6.00 275 $1,650.00 ~ Remove concrete sidewalk SF 550 0.80 550 $440.00 4 Remove and Replace Bleachers LS 1 1850.00 1 $1,850.00 5 Common excavation (CV) Cy 350 20.00 350 $7,000.00 6 Subgrade preparation Sy 800 1.25 800 $1,000.00 7 Geotextile fabric, Type V SY 800 1.10 800 $880.00 8 4" PVC drain tile LF 365 12.00 365 $4,380.00 9 Select granular borrow TN 320 8.00 340.02 $2,720.16 10 Salvage and reinstall aggregate base CY 100 8.00 14 $112.00 11 Aggregate base, Class 5 TN 50 25.00 176.3 $4,407.50 12 5" concrete sidewalk SF 2475 5.10 2330 $11,883.00 13 411 concrete sidewalk SF 350 4.60 350 $1,610.00 14 Pedestrian curb ramp EA 2 250.00 2 $500.00 15 Bituminous base course, Type 31 B TN 45 75.00 49.5 $3,712.50 16 Bituminous wear course, Type 41 (2000) TN 45 85.00 49.5 $4,207.50 17 Restoration and Seeding LS 1 1500.00 1 $1,500.00 18 211 Sieve in concrete sidewalk EA 1 200.00 1 $200.00 Total Part 1 - Base Bid $49,365.16 Total Part 1 - Base Bid $49,365.16 Total Work Completed To Date $49,365.16 3400124 REQ2 Fir.al xis PROJECT PAYMENT STATUS OWNER CITY OF NEW HOPE BRA FILE NO. 34-00-124 CONTRACTOR HARD RIVES INC CHANGE ORDERS No. Date Description Amount Total Change Orders PAYMENT SUMMARY No. From To Payment Retainage Completed 1 08/22/2000 11/28/00 46,915.43 2,469.23 49,384.66 2 AND FINAL 11/29/2000 08/29/01 2,449.73 49,365.16 Material on Hand Total Payment to Date $49,365.16 Oriqinal Contract $46,755.00 RetainaQe Pay No. 2 AND FINAL Change Orders Total Amount Earned $49,365.16 Revised Contract $46,755.00 3400124REQ2Final.xls MIN ~ESOTA DepartrP..ent of Revenue ithh Iding Affid vit for This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of its subdivisions con make final payment to contractors. ntr ct /,::2.'7 ~ (<::-j7 / / vo rs # (0'73 . . J ,t' f.. /1, &JYT1',,'ti c ~ 1(-1 34 Please type or print clearly. This will be your moiling label for returning the completed form. 0-----------------\ Compan~ Jome Daytime phon~ I -itardr/rul, /;1C. I (101 *~f~g"tf& I Address ' , I Total contract amount I rl"IJ) l)LLiraI77.JJr. I $ .Jjq,~-3(/5. /(~ I City !//) I State Zip;.:...ode I Amount still due fr/ tiC; / vJ ~ ^ / ~ ,~ ,;? Z?l I $, } We:;. I? ~ "--!u(t'C~----W---D;;; +--/ c::x L : Minnesota v/ithholding tax ID number : 0 C/5-j?oL I Month/year wor}-began i q/OO ! Month/year ~r~nded I I:; le/ I Stock No. 5000134 (Rev. 11/96) Printed on recycled paper with 10% post-consumer waste using soy-based ink. Project number Projecl)dCblion I ../ I1ff/'I/ -!tuf)C-'-!Z2/):. ~/?(&Llrf / Address' City Yes 0 No If no, who did the work? Check the box that describes your involvement in the proiect and Fill in all information requested, D Sole contractor D Subcontractor Nome of contractor who hired you State Zip code rz:J' Prime contractor-If you subcontracted out any work on this project, all of your subcontractors must file their own IC-134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified IC~ 134. If you need more space, attach a separate sheet. Business name Address Owner/Officer Lk I il " ~? f~/ if In /'l/J./& /8dI7C/ (I rr~ 1/;//1//,. Y/.; i/~ //). J. / r:.,- r ...:;' ;;j ~7 ~ ~ k/ Fyr Ivlv ~ L/cJ /' I declare that all information I have filled in on this form is true and complete to the best of my knowledge and belief. I authorize the Department of Revenue to disclose pertinent information relating to this project, including sending copies of this form, to the prime contractor if I am a subcontractor, and to any subcontractors if I om 0 prime controctor, and to the contracting agency. Con if dor's signature Title . /0 L.' ).. II) j tW ) (L;(J;f- aryl, Mail to: M Dept. of Rev~nu~, Withholding Division, Mail Station 6610, Sf. Paul, MN 55146-6610 Date c;-,y c/O I Certificate of Compliance Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. DepartmegY"'qf R,e')enue approval Date . t"""}. ..,i:.........':':':.- ... ~ ' ~'~: ,:-:;<::{7';,:',,:::;.,"(: viIN'\JESOTA Department of Revenue o:<<}thholding Affidavit for co~~actQrs . ._> ~~JJj~QFfidovit must be approved by the Minnesota Deportment of RttV~~Jiue befoeft~J~e~~~p.te of Minnesota or any of its subdivisions can make final payment to contractors. ~,)tr ,:..',,-'/~ 2ir:z~~ ;'it~5~, ~t~._~ p. ..';".t;,~. .,'a.';lt ~:;~:J.:o';'.. ~~. ,-L .,,! ~t.~. (,~y; ~~~' M II ~-~~?;'~E! ~~:~~ >' _r~1 c: "; ~~~ o ,>~~ ::. :;;=.S';tf:; ~ a:,: i ")ck No, 5000134 " 11/96) IC-l 34 Please type or print dearly. This will be your mailing label for returning the completed Form. 0-----------------\ C~PQny name , l\ : A~~$ Q~d 0 C~~ ~ \J} ~Qc\-C <'\ '-U\ ( : I " ''"\ \ ltG \ ~3--. G- ~"{ f--JL0 I I Cily ~. '. . \ Slole. Zip Code -, I \.. ~\~ R \. (sex:- _ _ r"'-lA.::.- _ SS 33 0 _./ $ <.i Daytime phone l1la~) ~ ',-7;J. S_'~- T 0101 contract amoun. t . . -::;r $. Q3/, ~u Amounl slill Clue a.. Minnesota withholding tox ID number j /,., (? " 6. ? t.j '7~,?..-:~ I. , Month/ye~r..work began I/~/' i ,.>. Month/year work ended ~ 11 11 I7/j() / L/ / ? 1 L-'^ C. k/ Project location.-:> C: \U'~ c- L~,\-e4- ~ e-< '.C' '\1\ eeL '\-1- L..,; City Project number ( (? C"t :3 Project owner Address r~ '. r \ \..., "', L t ~ \.. r~6~)N '(.A..V l?'\C f2.s:....- Did you hov~mployees work on this project? \ ~Yes 0 No If nOI who did the work? Stale Zip code Check the box that describes your involvement in the project and fill in all inFormation requested. o S,ole contractor '5t. Subcontractor Nome of contractor who hired you ~'d-, ~ .;,e S I 3:r\~ Address Qu....\..-~ ~)\ \C"f ~oc~:(:S Y'U,.SS314- ..~ , Prime contractor-If you subcontracted out any work on this project, all of your subcontractors must file their own IC-134 affidavits and have them certified by the Department of Revenue before you con file your affidavit. For each subcontractQr you had, fill in the information below and attach a copy of each subcontractor's certified IC-134. If you need more space, ottach a separate sheet. Business nome Address \ L\:L{ \ S Owner /Officer I declare thot 0/1 information I hove fjlled in on this Form is true and complele 10 the best of my know/edge and belieF. I authorize the Department of Revenue to disclose pertinent informa.fiO~...:". ing to this proiect, including sending copies of this form, /0 the prime contractor if J om 0 subcontractor, and to any subcontractors if J am a p;mle c~'ractor, and to the contracting agency. Contractor's sj9n~tu . /! ....., ...... Title '.' . /J , /. / Dote .~. ?'~ ~ 0Le f/k:S/Cldf c;-3-0/ Mail to: MN Dept. of Revenue, W' :'olding Division, Moil Station 6610, St. Paul, MN 55146.6610 Certificate of Compliance Based on records of the Minnesota Deportment of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tox from wages paid to employees relating to contract services with the state of Mi~nesoto ond/ or its subdivisions. Depqrtlftent of Revenue approval Dale !Ii . ..~,~.. 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