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HomeMy WebLinkAboutBids - Interior Brick Masonry RepairsCITY OF GALESBURG PURCHASING 55 West Tompkins Street Galesburg, IL 61401 Phone: 309/345-3678 BID FORM Name of Bidder m R Mason Contractor/a Division of River city Construction, LLC Business Address 101 Hoffer sane City, State, Zip Code East Peoria, TL 61611 Phone No. 309. 698 . 0035 Fax No. 309 • 698 . 0584 E-Mall Address: ddemin(amrmasorncontractor.com The Bidder above mentioned declares and certifies: First - That this bid is made without any previous understanding, agreement or connection with any other person, firm or corporation making a bid for the same purpose; and, is in all respects, fair and without collusion or fraud. Second- That no officer, employee or person whose salary is payable in whole or in part from the City of Galesburg is directly or indirectly interested in this bid or in any portion of the profits thereof. Third - That said bidder has carefully examined the Instructions to Bidders and the Specifications: and will, if successful in this bid, furnish and deliver at the prices bid within the time stated, the goods or services for which this bid is made. Fourth - That the prices quoted herein are net and exclusive of all taxes from which the City of Galesburg is exempt. Fifth - That said bidder has executed the Certificate of Compliance, and has submitted herewith. Sixth - That the cost of the goods or services which meets the requirements as set forth in the Instruction to Bidders and the Specifications aforementioned is: $ 14,595.00 Fourteen Thousand Five Hundred Ninety -Five Dollars and 00/100 11.04.2021 Date M R Mason Contractor/a Division of River City Constructions LLC Person, Firm, or Corporation General Manag er Authorized signature and title Printed Name of Individual r 1 .... e ,�nf 1�6 {.ar� +`�G.. i M �r Y a ��6 .:v - 1. �; Y • gg 3, ��°t '.i l `.. RETURN WITH BID TO THE CITY OF GALESBURG, ILLINOIS CERTIFICATE OF COMPLIANCE EMPLOYMENT SUPERVISORY SALES OFFICE SKILLED SEMI -SKILLED NON -SKILLED WHITE 2 1 31 BLACK 3 OTHER 1 MALE 2 1 35 FEMALE (PLEASE FILL IN THE NUMBER OF EMPLOYEES IN EACH CLASS) 1. THE CONTRACTOR OF COMPANY WILL NOT DISCRIMINATE AGAINST ANY EMPLOYEES OR APPLICANT FOR EMPLOYMENT BECAUSE OF RACE, CREED, COLOR, SEX, AGE, NATIONAL ORIGIN, HANDICAPPING CONDITION UNRELATED TO ABILITY TO PERFORM THE JOB; AND, WILL TAKE AFFIRMATIVE ACTION TO ENSURE THAT APPLICANTS ARE EMPLOYED WITHOUT REGARD TO THEIR RACE, CREED, COLOR, SEX, AGE, HANDICAP OR NATIONAL ORIGIN. SUCH ACTION SHALL INCLUDE, BUT NOT BE LIMITED TO, THE FOLLOWING: EMPLOYMENT, UPGRADING, DEMOTION OR TRANSFER, RECRUITMENT OR RECRUITMENT ADVERTISING, LAYOFF OR TERMINATION, RATES OF PAY OR OTHER COMPENSATION, AND SELECTION FOR TRAINING, INCLUDING APPRENTICESHIP. THE CONTRACTOR OR COMPANY AGREES TO POST, IN CONSPICUOUS PLACES, AVAILABLE TO EMPLOYEES AND APPLICANTS FOR EMPLOYMENT, NOTICES SETTING FORTH THE PROVISIONS OF THIS NON-DISCRIMINATION CLAUSE. 2. THE CONTRACTOR OR COMPANY WILL, IN ALL SOLICITATIONS OR ADVERTISEMENTS FOR EMPLOYEES OR ON THEIR BEHALF, STATE THAT ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO RACE, CREED, COLOR, SEX, AGE, HANDICAPPING CONDITION UNRELATED TO ABILITY OR NATIONAL ORIGIN. THE SAME SHALL HOLD TRUE WHEN RECRUITMENT SOURCES ARE USED TO SECURE APPLICANTS. 3. THE CONTRACTOR OR COMPANY AGREES TO NOTIFY ALL OF ITS SUBCONTRACTORS OF THEIR OBLIGATION TO COMPLY WITH THE NONDISCRIMINATION POLICY. 4. IN THE EVENT OF THE CONTRACTOR'S OR COMPANY'S NON-COMPLIANCE WITH THE NON-DISCRIMINATION CLAUSES OF THE CONTRACT OR PURCHASE OR WITH ANY OF SUCH RULES, REGULATIONS OR ORDERS, THE CONTRACT OR PURCHASE MAY BE CANCELLED, TERMINATED OR SUSPENDED IN WHOLE OR IN PART AND THE CONTRACTOR OR COMPANY MAY BE DECLARED INELIGIBLE FOR FURTHER CITY CONTRACTS OR PURCHASES IN ACCORDANCE WITH THE AFFIRMATIVE ACTION PROGRAM ADOPTED BY THE GALESBURG CITY COUNCIL AT THEIR MEETING ON AUGUST 6, 1990 M R Mason Contractor/a Division of BY: River City Construction, LLC BIDDER RETURN WITH BID CITY OF GALESBURG MUNICIPAL VENDORS HOLD HARMLESS AGREEMENT All vendors doing business with the City of Galesburg, Illinois, shall read and agree to sign this Hold Harmless Agreement. In lieu of the vendor signing this agreement, the City will accept being named as an additional insured on the vendor's general liability policy only as respects specific operations performed by the vendor on behalf of or on the premises of the City of Galesburg, Illinois. "In consideration of your permitting us, our servants, our agents, employees and representatives from time to time to enter upon or to place or maintain equipment upon premises owned or controlled by you for the purposes of servicing our account, we agree to indemnify and hold harmless the City and its' agents and employees from and against all claims for personal injury or property damage, including claims against the City, its' agents or servants, and all losses or expenses, including attorney's fees that may be incurred by the City in defending such claims, rising out of or resulting from the performance of the work and caused in whole or in part by any negligent act or omission of the Municipal Vendor, or anyone directly or indirectly employed by the Municipal Vendor or anyone for whose acts any of them may be liable, the indemnification obligation under this paragraph shall not be limited in anyway by any limitation on the amount or type of damages, compensation or benefits payable by or for the Municipal Vendor, under Workers' Compensation Acts, Disability Acts, or other Employee Benefit Acts." Subscribed and sworn to before me this November 3 , 20 21 Person, Firm, or orporation Dave bemmin, General Manager M R Mason Contractor/ a Division of River City Construction, LLC Notary Public "OFFICIAL SEAL" cz,�L COLLEEN A. MILLER*'*** 9 Notary Public, State of Illinois My Commission Expires 10-20-2022 M R Mason Contractor P. O. Box 1428 Peoria, IL 61655-1428 Phone: (309) 698-0035 Fax: (309) 698-0584 November 3, 2021 City of Galesburg 55 West Tompkins Street Galesburg, IL 61401 Attention: Purchasing Agent Regarding: Galesburg Water Division Pumping Station — Interior Brick Masonry Repairs To Whom It May Concern, M R Mason Contractor is pleased to provide you with the following information as part of our bid for the Interior Brick Masonry Repairs for Galesburg Water Division Pumping Station located at 920 West Main Street, Galesburg, Illinois. I. Number of days required to complete services under normal conditions: 7 days maximum 2. Estimated Start Date: November 15, 2021 3. Estimated Completion Date: on or before November 23, 2021 Should you have any questions or comments, please do not hesitate to contact me. Sincerely, M R Mason Contractor Dave Demmin General Manager MAIN OFFICE * 101 HOFFER LANE * E. PEORIA, IL 61611 THE AMERICAN INSTITUTE OF ARCHITECTS AIA Document A310 BID BOND MR Mason Contractor/Division of River City Construction, LLC KNOW ALL MEN BY THESE PRESENTS, that we P.O Box 1428, East Peoria, IL 61611 (Here insert full name and address or legal title of Contracted) as Principal, hereinafter called the Principal, and continantal casualty cosh Flo l� 15, N Franklin Street 17th Floor Chicago, IL 60606 (Here insert fall name and address or legal title of Surety) a corporation duly organized under the laws of the State of Illinois as Surety, hereinafter called the Surety, are held and frml bound unto CityrraasurorcIGalesburg }� 55 Wes, Tomykins,5treet Galesburg IL 61401 (Here insert full name and address or legal title of Owner) as Obligee, hereinafter called the Obligee, in the Sum of FIVE PERCENT OF AMOUNT OF BID Dollars ($ 5% ), For the payment of which sum well and truly to be made, the said Principal and the said Surety, bind ourselves, our heirs, executor, administrators, successors and assign, jointly and severally, firmly by these presents. lntnnor Brick Masonry Repairs at the Galesburg Water Division Pumping Station WHEREAS, the Principal has submitted a bid for locatoci at 920 West Main Street in the City of Galesburg, Illinois (Here insert full name, and description ofproject) NOW THEREFORE, if the Obligee shall accept the bid of the Principal and the Principal shall enter into a Contract with the Obligee in accordance with the terms of such bid, and give such bond or bonds as may be specified in the bidding payment of labor and material furnished in the prosecution thereof, or in the event of the failure of the Principal to enter hereof between the amount specified in said bid and such larger amount for which the Obligee may in good faith contract with another party to perform the Work covered by said bid, then this obligation. shall be null and void, otherwise to remain in full force and effect. r1 Signed and sealed this 3rd (Witness) day of November 2021 MR Mason Contractor/Division of River City Construcl ` (Seal) Dave Demmin, General Manager Continental Casualty Company (S - l (Witness) C!/ (Title Nicholas G. Yates Attorn ALA DOCUMENT A310 BID 13OND AIA FEBRUARY 1970 ED THE AMERICAN STITUTE OF ARCHITECTS, 1735 N.Y, AVE., N.W., WASHINGTON, D.C. 20006 r-C'oNSrA(/' • rk; SEAL , CHINO g THIS FORM MUST BE SUBMITTED WITH THE SEALED BID yry STATE OF IIlinois COUNTY OF Peoria I, Roberta J. Hall, Notary Public of Peoria County, in the State of Illinois, do hereby certify that Nicholas G. Yates, Attorney -in -Fact, of the Continental Casualty Company, who is personally known to me to be the same person whose name is subscribed to the foregoing instrument, appeared before me this day in person, and acknowledged that he signed, sealed and delivered said instrument, for and on behalf of the Continental Casualty Company, for the uses and purposes therein set forth. Given of my hand n t rial n s ' ember, 2021. OFFICIAL SEAL Roberta J. Hall, Notary lie ROBERTA J HALL My Commission )expires June 6, 2022 Notary Public, State of Illinois My Commission Expires 06-06-2022 POWER OF ATTORNEY APPOINTING INDIVIDUAL ATTORNEY -IN -FACT Know All Men By These Presents, That Continental Casualty Company, an Illinois insurance company, National Fire Insurance Company of Hartford, an Illinois insurance company, and American Casualty Company of Reading, Pennsylvania, a Pennsylvania insurance company (herein called "the CNA Companies"), are duly organized and existing insurance companies having their principal offices in the City of Chicago, and State of Illinois, and that they do by virtue of the signatures and seals herein affixed hereby make, constitute and appoint Nicholas G Yates, Brad A Gregurich, Paula G Chaney, Susan E Mansfield, Roberta J [fall, Individually of Peoria, IL, their true and lawful Attorneys) -in -Fact with full power and authority hereby conferred to sign, seal and execute for and on their behalf bonds, undertakings and other obligatory instruments of similar nature - In Unlimited Amounts - and to bind them thereby as fully and to the same extent as if such instruments were signed by a duly authorized officer of their insurance companies and a]I the acts of said Attorney, pursuant to the authority hereby given is hereby ratified and confirmed. This Power of Attorney is made and executed pursuant to and by authority of the By -Law and Resolutions, printed on the reverse hereof, duly adopted, as indicated, by the Boards of Directors of the insurance companies. In Witness Whereof, the CNA Companies have caused these presents to be signed by their Vice President and their corporate seals to be hereto affixed on this 20th day of Tune, 2021. �� GA5tlq�Ty � 1NSURgH o,�,vaMr o� OOFWORAre U n "' BRPOR4r c z Q a JULY 31, h Ls SEAL T y : i9oz r �a 1897 HARli b • Continental Casualty Company National Fire Insurance Company of Hartford American Ca lty Company of Re ing, Pennsylvania Paul T. Bruflat c.e President State of South Dakota, County of Minnehaba, ss: On this 20th day of June, 2021, before me personally carve Paul T. Bruflat tome known, who, being by me duly sworn, did depose and say: that he resides in the City of Sioux Falls, State of South Dakota; that lie is a Vice President of Continental Casualty Company, an Illinois insurance company, National Fire Insurance Company of Hartford, an Illinois insurance company, and American Casualty Company of Reading, Pennsylvania, a Pennsylvania insurance company described in and which executed the above instrument; that he knows the seals of said insurance companies; that the seals affixed to the said instrument are such corporate seals; that they were so affixed pursuant to authority given by the Boards of Directors of said insurance companies and that he signed his name thereto pursuant to like authority, and acknowledges same to be the act and deed of said insurance companies. #4r•a..4..4a44ray4ay44455a# + M.BENT i e EA NOTARY PUBLIC + i SBA' SOUTH DA. SEAL My Commission Expires March 2, 2026 M. Bent Notary Public CERTIFICATE 1, D. Johnson, Assistant Secretary of Continental Casualty Company, an Illinois insurance company, National Fire Insurance Company of Hartford, an Illinois insurance company, and American Casualty Company of Reading, Pennsylvania, a Pennsylvania insurance company do hereby certify that the Power of Attorney herein above set forth is still in force, and further certify that the By -Law and Resolution of the Board of Directors of the insurance companies printed on the reverse hereof is still in force. In testimony whereof I have hereunto subscribed my name and affixed the seal of the said insurance companies this 3rd day of November, 2021. OAS U.gt?Y iN5URq, pfi° ANY OF,�, xu E` YY 'Pp�s ooaP;RArfi�G / G yORPgRgr�B p rd `7 7� J!1►Y 31,SEAL y a 1891 8ARt4 b • Form F6853-4/2012 Continental Casualty Company National Fire Insurance Company of Hartford American Casualty Company of Reading, Pennsylvania D. 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Please fill out this form as completely as possible to ensure proper payment to you. Please return completed form as soon as possible to The City of Galesburg at the above address or fax number. Please call 309-345-3674 with any questions. BUSINESS NAME: M R Mason Contractcr/ a Division of River City Construction, LLC INDIVIDUAL NAME: N/A (for Sole Proprietors as appears on Social Security Card) BUSINESS ADDRESS: 1.01 Hoffer Lane CITY, STATE, ZIP: East Peoria, T11 i not s YOUR TAXPAYER IDENTIFICATION NUMBER: 37-1366545 (i or business tax ID. i OR, YOUR SOCIAL SECURITY NUMBER: N/A If using SSN, enter the name on the card above as Individual Name.) PLEASE CHECK APPROPRIATE BOX: Individual/Sole Proprietor ❑X Corporation Partnership F-10ther YOUR COMPANY PROVIDES: Legal Services Services Materials Other ARE YOU SUBJECT TO BACKUP WITHHOLDING? L]YeS FX]No PERSON TO CONTACT: Dave Demmin, General man,73ger PHONE NUMBER: 309. 698. 0035 UNDER PENALTY OF PERJURY, I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS CORRECT AND COMPLETE. Colleen A. Miller .03.?0�1 Signature Date Business Manaoer Title CITY OF GALESBURG PURCHASING 55 West Tompkins Street Galesburg, IL 61401 Phone: 309/345-3678 BID FORM Name of Bidder Otto Baum Company, Inc. Business Address 866 N. Main Street City, State, Zip Code Morton !L 61550 Phone No. 309-266-7114 Fax No. NIA E-Mail Address: estimating@ottobaum.com The Bidder above mentioned declares and certifies: First - That this bid is made without any previous understanding, agreement or connection with any other person, firm or corporation making a bid for the same purpose; and, is in all respects, fair and without collusion or fraud. Second- That no officer, employee or person whose salary is payable in whole or in part from the City of Galesburg is directly or indirectly interested in this bid or in any portion of the profits thereof. Third - That said bidder has carefully examined the Instructions to Bidders and the Specifications: and will, if successful in this bid, furnish and deliver at the prices bid within the time stated, the goods or services for which this bid is made. Fourth - That the prices quoted herein are net and exclusive of all taxes from which the City of Galesburg is exempt. Fifth - That said bidder has executed the Certificate of Compliance, and has submitted herewith. Sixth - That the cost of the goods or services which meets the requirements as set forth in the Instruction to Bidders and the Specifications aforementioned is: $ 19,565.00 11 /3/2021 O\\ C ONj� Date Otto Baum Company, inc. Qp,PORgT Person, Firm, or Corporation SEAS.. � - - 1969 President %,� �L�Ip��• A orized signature and title Terry Baum Printed Nance of Individual SPECIAL PROVISIONS PREVAILING RATE: Not less than the Prevailing Rate of Wages as found by the City of Galesburg, or the Department of Labor, or determined by the Court of Review, shall be paid to all Laborers, Workmen and Mechanics performing work under this contract. CERTIFIED PAYROLLS: All work is subject to the Davis -Bacon Act and all prevailing wage laws. The contractor and all subcontractors shall submit certified copies of his payroll weekly for all work undertaken on the project. Failure to keep current on submittal of payrolls shall be cause to withhold payment for completed work. PROOF OF INSURANCE: The contractor shall carry insurance as required by the Standard Provisions. Proof of various insurance coverage shall be submitted to the City and shall be kept in force until all work to be performed under the terms of the contract has been accepted SPECIAL PROVISIONS TO COVER LABOR AND MATERIAL PAYMENT The Contractor shall not commence work under this contract until he has obtained a labor and Material Payment Bond, which has been approved by the City, nor shall the Contractor allow any subcontractor to commence work on his subcontract until subcontractor has a similar bond or the Contractor's bond covers the subcontractor's Labor and Material Payment. SPECIAL PROVISIONS TO COVER CONTRACTOR'S AND MUNICIPAL VENDORS (As Amended 05/17/16) The Contractor, or Municipal Vendor, shall not commence work under this contract until he has obtained all insurance required under this section, and such insurance has been approved by the City; nor shall the Contractor allow any sub -contractor to commence work on his sub -contract until all similar insurance required of the sub -contractor has been approved by the City. The Contractor shall obtain and thereafter keep in force the following insurance coverages provided by insurance companies acceptable to the City and authorized to transact business under the laws of the State of Illinois. The insurance companies providing coverage shall be rated in the Best's Key Rating Guide. The City will accept companies with a rating not lower than B+ provided the financial size category is VII or larger. Companies rated A- or better shall have a financial size category of not less than Vl. Coverage limits shall be written at not less than the minimum specified in this section. Higher minimum limits and additional coverage may be specified by a special provision elsewhere in the contract. Whether stated in this section or elsewhere, the City does not warrant the adequacy of the types of insurance coverage or the lints of liability specified, (a) Workers Compensation and Employers Liability (1) Workers compensation shall be provided according to the provisions of the Illinois Worker's Compensation Act, as amended. Notwithstanding the rating and financial size categories stated in this section, coverage may be provided by a group self -insurer authorized in Section 4(a) of the Act and approved pursuant to the rules of the Illinois Department of Insurance, (2) Employers Liability. a. Each Accident $500,000 b. Disease -policy limit $500,000 c. Disease -each employee $500,000 (b) Commercial General Liability. Required liability insurance coverage shall be written in the occurrence form and shall provide coverage for operations of the Contractor; operations of subcontractors (contingent or protective liability), completed operations; broad form property damage and hazards of explosion, collapse and underground; and contractual liability. The general aggregate limit shall be endorsed on a per project basis. (1) General Aggregate Limit $2,000,000 (2) Products -Completed Operation Aggregate Limit $2,000,000 (3) Each Occurrence Limit $1,000,000 The coverage shall provide by an endorsement in the appropriate manner and form, the City, its officers, and employees shall be named as additional insureds with respect to the policies and any umbrella excess liability coverage for occurrences arising in whole or in part out of the work and operations performed, The City may accept a separate owner's protective liability policy in lieu of the City, it's officers, and employees being insureds on the Contractor's policies. (a) Commercial Automobile Liability. The policy shall cover owned, non -owned, and hired vehicles. Bodily Injury & Property Damage Liability Limit Each Occurrence $1,000,000 (d) Umbrella Liability. Any policy shall provide excess limits over and above the other insurance limits stated in this Article. The Contractor may purchase insurance for the full lints required or by a combination of primary policies for lesser limits and remaining limits provided by the umbrella policy. All insurance shall remain in force during the period covering occurrences happening on or after the effective date and remain in effect during performance of the work and at all times thereafter when the Contractor may be correcting, removing, or replacing defective work until notification of the date of final inspection. Termination or refusal to renew shall not be made without 30 days prior written notice to the City by the insurer and the policies shall be endorsed so as to remove any language restricting or limiting liability concerning this obligation. Certified copies of the original policies or certificates) of insurance by the insuror(s) issuing the policies and endorsements setting forth the coverage, limits, and endorsements shall be filed with the City before the City will execute the contract. A certificate of insurance shall include a statement "the coverage and limits conform to the minimums required by Article 107.27 of the Standard Specifications for Road and Bridge Construction", Any exception or deviation shall be brought to the attention of the City for a ruling of acceptability. In no event shall any failure of the City to receive policies or certificates or to demand receipt be construed as a waiver of the Contractor's obligation to obtain and keep in force the required insurance. All costs for insurance as specified herein will be considered as included in the cost of the contract. The Contractor shall, at his/her expense and risk of delay, cease operations if the insurance required is terminated or reduced below the required amounts of coverage. Coverage in the minimum amounts set forth herein shall not be construed to relieve the Contractor from his/her obligation to indemnify in excess of the coverage according to the contract. The contractor, prior to execution of the contract, shall file with the City copies of completed certificates of insurance, satisfactory to the City, to afford protection against all claims for damages to public or private property, and injuries to persons, arising out of and during the progress of the work to its completion, being whenever the improvement called for by the contract shall have been completely performed on the part of the contractor and all parts of the work have been approved and accepted by the City, and the final payment made. The policy of insurance shall include the City as an additional insured or provide separate coverage with an Owner's Protective policy. *Language of coverage in this section taken from IUDT Standard Specifications adopted April 1, 2016 RETURN WITH BID TO THE CITY OF GALESBURG, ILLINOIS CERTIFICATE OF COMPLIANCE EMPLOYMENT SUPERVISORY SALES OFFICE SKILLED SEMI -SKILLED NON -SKILLED WHITE 17 6 140 14 67 BLACK 1 OTHER 1 2 MALE 16 1 145 16 76 FEMALE 1 7 0 1 (PLEASE FILL IN THE NUMBER OF EMPLOYEES IN EACH CLASS) 1. THE CONTRACTOR OF COMPANY WILL NOT DISCRIMINATE AGAINST ANY EMPLOYEES OR APPLICANT FOR EMPLOYMENT BECAUSE OF RACE, CREED, COLOR, SEX, AGE, NATIONAL ORIGIN, HANDICAPPING CONDITION UNRELATED TO ABILITY TO PERFORM THE JOB; AND, WILL TAKE AFFIRMATIVE ACTION TO ENSURE THAT APPLICANTS ARE EMPLOYED WITHOUT REGARD TO THEIR RACE, CREED, COLOR, SEX, AGE, HANDICAP OR NATIONAL ORIGIN. SUCH ACTION SHALL INCLUDE, BUT NOT BE LIMITED TO, THE FOLLOWING: EMPLOYMENT, UPGRADING, DEMOTION OR TRANSFER, RECRUITMENT OR RECRUITMENT ADVERTISING, LAYOFF OR TERMINATION, RATES OF PAY OR OTHER COMPENSATION, AND SELECTION FOR TRAINING, INCLUDING APPRENTICESHIP, THE CONTRACTOR OR COMPANY AGREES TO POST, IN CONSPICUOUS PLACES, AVAILABLE TO EMPLOYEES AND APPLICANTS FOR EMPLOYMENT, NOTICES SETTING FORTH THE PROVISIONS OF THIS NON-DISCRIMINATION CLAUSE. 2. THE CONTRACTOR OR COMPANY WILL, IN ALL SOLICITATIONS OR ADVERTISEMENTS FOR EMPLOYEES OR ON THEIR BEHALF, STATE THAT ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO RACE, CREED, COLOR, SEX, AGE, HANDICAPPING CONDITION UNRELATED TO ABILITY OR NATIONAL ORIGIN. THE SAME SHALL HOLD TRUE WHEN RECRUITMENT SOURCES ARE USED TO SECURE APPLICANTS. 3. THE CONTRACTOR OR COMPANY AGREES TO NOTIFY ALL OF ITS SUBCONTRACTORS OF THEIR OBLIGATION TO COMPLY WITH THE NON-DISCRIMINATION POLICY. 4. IN THE EVENT OF THE CONTRACTOR'S OR COMPANY'S NON-COMPLIANCE WITH THE NON-DISCRIMINATION CLAUSES OF THE CONTRACT OR PURCHASE OR WITH ANY OF SUCH RULES, REGULATIONS OR ORDERS, THE CONTRACT OR PURCHASE MAY BE CANCELLED, TERMINATED OR SUSPENDED IN WHOLE OR IN PART AND THE CONTRACTOR OR COMPANY MAY BE DECLARED INELIGIBLE FOR FURTHER CITY CONTRACTS OR PURCHASES IN ACCORDANCE WITH THE AFFIRMATIVE ACTION PROGRAM ADOPTED BY THE GALESBURG CITY COUNCIL AT THEIR MEETING ON AUGUST 6, 1990 BY: Otto Baum Company, Inc. BIDDER RETURN WITH BID CITY OF GALESBURG MUNICIPAL VENDORS HOLD HARMLESS AGREEMENT All vendors doing business with the City of Galesburg, Illinois, shall read and agree to sign this Hold Harmless Agreement. In lieu of the vendor signing this agreement, the City will accept being named as an additional insured on the vendor's general liability policy only as respects specific operations performed by the vendor on behalf of or on the premises of the City of Galesburg, Illinois. "in consideration of your permitting us, our servants, our agents, employees and representatives from time to time to enter upon or to place or maintain equipment upon premises owned or controlled by you for the purposes of servicing our account, we agree to indemnify and hold harmless the City and its' agents and employees from and against all claims for personal injury or property damage, including claims against the City, its' agents or servants, and all losses or expenses, including attorney's fees that may be incurred by the City in defending such claims, rising out of or resulting from the performance of the work and caused in whole or in part by any negligent act or omission of the Municipal Vendor, or anyone directly or indirectly employed by the Municipal Vendor or anyone for whose acts any of them may be liable, the indemnification obligation under this paragraph shall not be limited in anyway by any limitation on the amount or type of damages, compensation or benefits payable by or for the Municipal Vendor, under Workers' Compensation Acts, Disability Acts, or other Employee Benefit Acts." ,{{y{IlEllr, C Subscribed and sworn to before me thisNovember 3rd, 20 21 _o. SEAL `��rrJ�ts For Otto Baum Company, Inc. P on, Firm, or Corporation Aa Notary Public OFFICIAL SEAL MOWE M. WMHT NOTARY PUBLIC, STATE OF ILLINOIS MY COMMISSION EXPIRES 08-05-2024 COMMISSION NO.914435 THE AMERICAN INSTITUTE OF ARCHITECTS ALA Document A310 BID BOND Otto Baum Company. Inc. KNOW ALL MEN BY THESE PRESENTS, that we 866 N Main St, Morton, IL 61550 (Here insert fall name acid address or 1"aI title of Contracted as Principal, hereinafter called the Principal, and Travelers Casualty and Surety Company of .America OrteTowerSquare, Hartford. CT 06183-6014 (Here insert full name and address or legal title of Surety) a corporation duly organized under the laws of the State of Connecticut as Surety, hereinafter called the Surety, are held antt firmly bound Unto City Treasurer of Galesburg, -15 w Tom 3 ins St, Galesburg, lL 61401 (Here insert Lull name and address or tegat title of Owaer) as Obligee, hereinafter called the Obligee, in the stun of Rive Percent of Arnount Bid Dollars ($ 5% For the payment of which sum well and truly to be made, the said Principal and the said Surety, bind ourselves, our heirs, executor, administrators, successors and assign, jointly and severally, firmly by these presents. WHEREAS, the Principal has submitted a bid for Interior Masonry Repairs at the Pumping Station (Ilere insert rulI name, and description orprojea) NOW THEREFORE, if the Obligee shall accept the bid of the Principal and the Principal shall enter into a Contract with the Obligee in accordance with the terins of such bid, and give such bond or bonds as may be specified in the bidding payment of labor and material ftlmished in the prosecution thereof, or in the event of the failure of the Principal tQ yntter hereof between the amount specified in said bid and such larger amount for which the Obligee may in good,l'ay i tjt dV,,f with another party to perform. the Work covered by said bid, then this obligation shall be null and void, ovi remain in full force and effect. pRPaRA� O G Signed and sealed this 3rd day of November 2021 y t SEAL : Z 1969 Otto Baum Company, -Inc, �� �Lf..... • `1 (Principal (Seal) ''z'``�rltttiittttt�sv``• (Title) Terry L um, President See Attached Notary Page (Witness) Travelers Casualty amd Surety Company of American (Surety} (S (Title) Claire kl Fahrizius, Attorney -Fact AIA DOC:UMENl' A310 BID 13OND AIA FEBRUARy 1970 ED T'1- E AMERIC:AN 1NS'ltl' TE OF ARC'HI'1'ECT'S, 1715 N,y, AVE.. N.W., WASHINGTON, D.C. 20006 THIS FORM MUST BE SUBMITTED WITH THE SEALED BID STATE OF ARIZONA COUNTY OF MARICOPA On this 31 day of November, 2021 before me personally appeared Claire M Fabrizius with whom I am personally acquainted, who, being by me duly sworn said: That he/she is Attorney - in -Fact of Travelers Casualty and Surety Company of America, Hartford, CT and that said seal affixed to said instrument is such corporate seal, that was so affixed by authority of the Board of Directors thereof and of his/her office under the Standing Resolutions of said Company; and that he/she signed his/her name thereto as Attorney -in -Fact by like authority. David Buckman NOTARY STAMP My commission expires: i y" rrr DAVIL) BUCKMAN Notary Pubhic, Slate of Arizona Marico6a County Com,jjission # 556509 My CniramissiDn Exp!reg Travelers Casualty and Surety Company of America t��Iii Travelers Casualty and Surety Company RAVELi 1 g St. Paul Fire and Marine Insurance Company POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That Travelers Casualty and Surety Company of America, Travelers Casualty and Surety Company, and St. Paul Fire and Marine Insurance Company are corporations duly organized under the laws of the State of Connecticut (herein collectively called the "Companies"), and that the Companies do hereby make, constitute and appoint Claire M Fabrizius of FRISCO , Texas , their true and lawful Attorneys) -in -Fact to sign, execute, seal and acknowledge any and all bonds, recognizances, conditional undertakings and other writings obligatory in the nature thereof on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. IN WITNESS WHEREOF, the Companies have caused this instrument to be signed, and their corporate seals to be hereto affixed, this 21st day of April, 2021. Room aN7 VA »". State of Connecticut By: City of Hartford ss. Robert L. Rans , : `enior Vice President On this the 21st day of April, 2021, before me personally appeared Robert L. Raney, who acknowledged himself to be the Senior Vice President of each of the Companies, and that he, as such, being authorized so to do, executed the foregoing instrument for the purposes therein contained by signing on behalf of said Companies by himself as a duly authorized officer. IN WITNESS WHEREOF, I hereunto set my hand and official seal. My Commission expires the 30th day of June, 2026 Maio. Anna P. Nowik, Notary Public This Power of Attorney Is granted under and by the authority of the following resolutions adopted by the Boards of Directors of each of the Companies, which resolutions are now in full force and effect, reading as follows: RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President, any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary may appoint Attorneys -in -Fact and Agents to act for and on behalf of the Company and may give such appointee such authority as his or her certificate of authority may prescribe to sign with the Company's name and seal with the Company's seal bonds, recognizances, contracts of indemnity, and other writings obligatory in the nature of a bond, recognizance, or conditional undertaking, and any of said officers or the Board of Directors at any time may remove any such appointee and revoke the power given him or her; and It is FURTHER RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice Presidont or any Vice President may delegate all or any part of the foregoing authority to one or more officers or employees of this Company, provided that each such delegation is in writing and a copy thereof is filed In the office of the Secretary; and it is FURTHER RESOLVED, that any bond, recognizance, contract of indemnity, or writing obligatory in the nature of a bond, recognizance, or conditional undertaking shall be valid and binding upon the Company when (a) signed by the President, any Vice Chairman, any Executive Vice President, any Senior Vice President or any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary and duly attested and sealed with the Company's seal by a Secretary or Assistant Secretary; or (b) duly executed (under seal, If required) by one or more Attorneys -in -Fact and Agents pursuant to the power prescribed In his or her certificate or their certificates of authority or by one or more Company officers pursuant to a written delegation of authority; and It is FURTHER RESOLVED, that the signature of each of the following officers; President, any Executive Vice President, any Senior Vice President, any Vice President, any Assistant Vice President, any Secretary, any Assistant Secretary, and the seal of the Company may be affixed by facsimile to any Power of Attorney or to any certificate relating thereto appointing Resident Vine Presidents, Resident Assistant Secretaries or Attorneys -in - Fact for purposes only of executing and attesting bonds and undertakings and other writings obligatory in the nature thereof, and any such Power of Attorney or certificate bearing such facsimile signature or facsimile seal shall be valid and binding upon the Company and any such power so executed and certiflod by such facsimile signature and facsimile seal shall be valid and binding on the Company in the future with respect to any bond or understanding to which it is attached. I, Kevin E. Hughes, the undersigned, Assistant Secretary of each of the Companies, do hereby certify that the above and foregoing is a true and correct copy of the Power of Attomey executed by said Companies, which remains in full force and effect. Dated this 3rd day of November , 2D21 iurrrs irroRD:.. . Kevin E. Hughes, Asst tant Secretary Tb verify the authenticity of this Power ofAttorney, please call ups at Y-800-421-388D. Please refer to the above -named Attorney(s)-In-Fact and the details of the ,band to which this Powerof Attorney is attached, THIS FORM IS BASED ON IRS REQUIRMENTS FOR THE SAME ESSENTIAL INFORMATION AS A W-9 RETURN TO: CITY OF GALESBURG OR FAX TO: 309-343-4765 ATTN: A/P 55 W TOMPKINS ST GALESBURG, IL 61401 The following information is needed to complete your vendor file and to comply with IRS requirements. Please fill out this form as completely as possible to ensure proper payment to you. Please return completed form as soon as possible to The City of Galesburg at the above address or fax number. Please call 309-345-3674 with any questions. BUSINESS NAME: Otto Baum Company. Inc. INDIVIDUAL NAME: Terry Baum (for Sole Proprietors as appears on Social Security Card) BUSINESS ADDRESS: 866 North Main Street CITY, STATE, ZIP: Morton, IL 61550 YOUR TAXPAYER IDENTIFICATION NUMBER: 37-0795665 (FEIN or business tax ID. No.) OR, YOUR SOCIAL SECURITY NUMBER: N/A If using SSN, enter the name on the card above as Individual Name.) PLEASE CHECK APPROPRIATE BOX: Individual/Sole Proprietor Corporation Partnership YOUR COMPANY PROVIDES: Legal Services r7i A IServices Materials ARE YOU SUBJECT TO BACKUP WITHHOLDING? Yes PERSON TO CONTACT: Carl Cale PHONE NUMBER: 309-266-7114 Other NIA _ Other N/A „ ❑X No UNDER PF,,NALTY OF PERJURY, I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS CORRECT AND COMPLETE. ,k--) '' 11 /3/2021 Signature Date President Title PURCHASING 55 West Tompkins Street: Galesburg, It- 61401 Phone' 309/345-3679 BID FORM Name of Bidder AtGo Masonry LLG Business Address 9998 north 2200th rd City, State, Zip Code Sciota, IL 61475 Phone No. _ 309.536.1505 T Fax No, E-Mail Address: derekcooper@atcomasonry.cooh The Bidder above mentioned declares and certifies: First - That this bid is made without any previous understanding, agreement or connection with any other person, firm or corporation making a bid for the same purpose; and, is in all respects, fair and without collusion or fraud. Second- That no officer, employee or person whose salary is payable in whole or in part from the City of Galesburg is directly or indirectly interested in this bid or in any portion of the profits thereof. Third - That said bidder has carefully examined the Instructions to Bidders and the Specifications: and will, if successful in this bid, furnish and deliver at the prices bid within the time stated, the goods or services for which this bid is made. Fourth - That the prices quoted herein are net and exclusive of all taxes from which the City of Galesburg is exempt. Fifth - That said bidder has executed the Certificate of Compliance, and has submitted herewith. Sixth - That the cost of the goods or services which meets the requirements as set forth in the Instruction to Bidders and the Specifications aforementioned is: $ 25,300 11/1/2021 Date AtCo Masonry LLC Person, Firm, or Corporation Authorizesignature �afrHi4g--___ Derek Cooper Printed Name of Individual RETURN WITH BID TO THE CITY OF GALESBURG, ILLINOIS CERTIFICATE OF COMPLIANCE EMPLOYMENT SUPERVISORY SALES OFFICE SKILLED SEMI -SKILLED NON -SKILLED WHITE 1 3 2 2 BLACK OTHER MALE 1 1 2 2 FfyMALE 2 (PLEASE FILL IN THE NUMBER OF EMPLOYEES IN EACH CLASS) 1. THE CONTRACTOR OF COMPANY WILL NOT DISCRIMINATE AGAINST ANY EMPLOYEES OR APPLICANT FOR EMPLOYMENT BECAUSE OF RACE, CREED, COLOR, SEX, AGE, NATIONAL ORIGIN, HANDICAPPING CONDITION UNRELATED TO ABILITY TO PERFORM THE JOB; AND, WILL TAKE AFFIRMATIVE ACTION TO ENSURE THAT APPLICANTS ARE EMPLOYED WITHOUT REGARD TO THEIR RACE, CREED, COLOR, SEX, AGE, HANDICAP OR NATIONAL ORIGIN. SUCH ACTION SHALL INCLUDE, BUT NOT BE LIMITED TO, THE FOLLOWING: EMPLOYMENT, UPGRADING, DEMOTION OR TRANSFER, RECRUITMENT OR RECRUITMENT ADVERTISING, LAYOFF OR TERMINATION, RATES OF PAY OR OTHER COMPENSATION, AND SELECTION FOR TRAINING, INCLUDING APPRENTICESHIP. THE CONTRACTOR OR COMPANY AGREES TO POST, IN CONSPICUOUS PLACES, AVAILABLE TO EMPLOYEES AND APPLICANTS FOR EMPLOYMENT, NOTICES SETTING FORTH THE PROVISIONS OF THIS NON-DISCRIMINATION CLAUSE. 2, THE CONTRACTOR OR COMPANY WILL, IN ALL SOLICITATIONS OR ADVERTISEMENTS FOR EMPLOYEES OR ON THEIR BEHALF, STATE THAT ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO RACE, CREED, COLOR, SEX, AGE, HANDICAPPING CONDITION UNRELATED TO ABILITY OR NATIONAL ORIGIN. THE SAME SHALL HOLD TRUE WHEN RECRUITMENT SOURCES ARE USED TO SECURE APPLICANTS. 3. THE CONTRACTOR OR COMPANY AGREES TO NOTIFY ALL OF ITS SUBCONTRACTORS OF THEIR OBLIGATION TO COMPLY WITH THE NON-DISCRIMINATION POLICY. 4. IN THE EVENT OF THE CONTRACTOR'S OR COMPANY'S NON-COMPLIANCE WITH THE NON-DISCRIMINATION CLAUSES OF THE CONTRACT OR PURCHASE OR WITH ANY OF SUCH RULES, REGULATIONS OR ORDERS, THE CONTRACT OR PURCHASE MAY BE CANCELLED, TERMINATED OR SUSPENDED IN WHOLE OR IN PART AND THE CONTRACTOR OR COMPANY MAY BE DECLARED INELIGIBLE FOR FURTHER CITY CONTRACTS OR PURCHASES IN ACCORDANCE WITH THE AFFIRMATIVE ACTION PROGRAM ADOPTED BY THE GALESBURG CITY COUNCIL AT THEIR MEETING ON AUGUST 6, 1990 BY:U-_�---- BIDDER DocuSign Envelope ID: C1DB8E5B-866E-496C-A35A-B6BA2OC413C7 TTIE A.MFRIC.N INSTITUTE OF ARCMTFCTS ATA Document A-'4 lit BID BOND Bond 465679608 AtCe Masonry LLC KNOW ALL MEINT BY THESE PRESENTS, atat we 10681 N. 2200thRd., Good Hope, IL 61438 Mere in crt full rune and address or legal title of Corntrl€€€e d as Principal, hereinalftc- calla] the Principal, and WESTERN SURETY COMPANY (Herd in ri. 11 nam d addr - n- legal u 1q of Suretx) 151 l o Frar m, l 7t i Floor, C€htcago, IL 60606 a corporation duly organized under the laws of the State of South Dakota as Surety, thereinafter called the Surety, are held and frinly bound unto City of.Galesburg � ._......__. 5- W. Tompkins Street, Gateburg , M 61402-1387 ahcre insw, full name arid' JI"c"s oor Icgnl tit I of owr&j as Obligee, hereinafter called the Obligcc, in the sum of Five Percent of Amount Bid 5% Dollars (S }, For the payn-tent of which sum well and truly to by made, the said. Principal and the said Surety, bind. ourselves, our heirs, e%ecutor; administratc�r-s, successors and assign jointly' anti severally, fmnly by these presets. NUEREAS, thz. Principal has submitted a bid for Interior Brick Masonry at The Galesburg Water Division Pumping Station 920 W. Main St., Galesburg, IL 61401 (Rere inse€t full nzne, a€id description of pre jectl TIMREFORE, if the Obligee shall aQcept the bid of the Principal and the Principal shall ether into a Contract with the Obliggee in accorda nee with the tarns of such bid- and give such bond or bonds as may be spccif.ed in the bidding payment of labor and material furnished i1.1 the prosecution thtxe f, or in the event of the failure of the Principal to enter hereof between the anioutht specified in said bid and such latrgeramount for which the Obligee may in goad faith contract ,with another party to perfom-t the Work covered by said bid, then this obligation shall be null and void, otlrenvisc to remain in full force and tifte�,t. Signed and sealed this �� J°ocuSigned 6y: S Z, IC°ocuSigned 6y: 54(� s 7Z )'ffi... 3rd day of November *20 21 ooca5 lr Wasonry LLC r-- � — caRPORArF 9.. SEAL Managing Member % _ (Title) € , WESTERN SURETY COMPANY CORPORQrF� SEAL 12Ff ,+Ft�s"aty L, Johnson Attorney in Fact € ' I:� I)t)t I rE T A3111 P1I? RCTli3 AT_ F- ,RRI'AR Y 19 70 F.T3' THE rti.MVJF It nl+i I\ST1T ;TF., eF AP(--141 F..r'1S, 1735 N.Y. AVR., .v.tY., WA-SSPINWITON, D.C. 200116 THIS FORM MUST BE SUBMITTED WITH THE SEALLED BID Western Surety Company POWER OF ATTORNEY - CERTIFIED COPY Bond No. 6567960 Know All Men By These Presents, that WESTERN SURETY COMPANY, a corporation duly organized and existing under the laws of the State of South Dakota, and having its principal office in Sioux Falls, South Dakota (the "Company'), does by these presents make, constitute and appoint Katy la_ Johnson its true and lawful attorney(s)-in-fact, with full power and authority hereby conferred, to execute, acknowledge and deliver for and on its behalf as Surety, bonds for: Principal: Atco Masonry LLC Obligee: City of Galesburg Treasurer Amount: $1, 000, 000. 00 and to bind the Company thereby as fully and to the same extent as if such bonds were signed by the Vice President, sealed with the corporate seal of the Company and duly attested by its Secretary, hereby ratifying and confirming all that the said attorney(s)-in- fact may do within the above stated limitations. Said appointment is made under and by authority of the following bylaw of Western Surety Company which remains in full force and effect. "Section 7, All bonds, policies, undertakings, Powers of Attorney or other obligations of the corporation shall be executed in the corporate name of the Company by the President, Secretary, any Assistant Secretary, Treasurer, or any Vice President or by such other officers as the Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant Secretary, or the Treasurer may appoint Attorneys in Fact or agents who shall have authority to issue bonds, policies, or undertakings in the name of the Company. The corporate seal is not necessary for the validity of any bonds, policies, undertakings, Powers of Attorney or other obligations of the corporation. The signature of any such officer and the corporate seal may be printed by facsimile." If Bond No.65h79608 is not issued on or before midnightof February 3rd 2022 all authority conferred in this Power of Attorney shall expire and terminate. In. Witness Whereof, Western Surety Company has caused these presents to be signed by its Vice President, Paul T. Bruflat, and its corporai%mLtobeaffixed this _ 3rd„clay of November 1 2021 YL e JIF^O MIST ss WES / SUR Y COMPANY Paul T ruflat, Vice President On ffiif z . = a — day of, November , in the year 2021 , before me, a notary public, personally appeared Paul T. Bruflat, who being to me duly sworn, acknowledged that he signed the above Power of Attorney as the aforesaid officer of WESTERN SURETY COMPANY and acknowledged said instrument to be the voluntary act and deed of sai corporation, s M. BENT s s SEPAL NOTARY PUBLIC — s r SOUTH DAKOTA s Notary Public - South Dakota s +��-,5hhygNsy F.y ^�,�5�-,khhyy�a4 + My Commission Expires March 2, 2026 I the undersigned officer of Western Surety Company, a stock corporation of the State of South Dakota, do hereby certify that the attached Power of Attorney is in full force and effect and is irrevocable, and furthermore, that Section 7 of the bylaws of the Company as set forth in the Power of Attorney is now in force. In testimony whereof, I have hereunto set my hand and seal of Western Surety Company this November 2021 day of WES . E �SURF Y COMPANY Paul Tkrufllt, Vice President To validate bond authenticity, go to www.criasurety.com > Owner/Obligee Services > Validate Bond Coverage. Form F5306-11•-2020 RETURN WITH BID CITY OF GALESBURG MUNICIPAL VENDORS HOLD HARMLESS AGREEMENT All vendors doing business with the City of Galesburg, Illinois, shall read and agree to sign this Hold Harmless Agreement. In lieu of the vendor signing this agreement, the City will accept being named as an additional insured on the vendor's general liability policy only as respects specific operations performed by the vendor on behalf of or on the premises of the City of Galesburg, Illinois. "In consideration of your permitting us, our servants, our agents, employees and representatives from time to time to enter upon or to place or maintain equipment upon premises owned or controlled by you for the purposes of servicing our account, we agree to indemnify and hold harmless the City and its' agents and employees from and against all claims for personal injury or property damage, including claims against the City, its' agents or servants, and all losses or expenses, including attorney's fees that may be incurred by the City in defending such claims, rising out of or resulting from the performance of the work and caused in whole or in part by any negligent act or omission of the Municipal Vendor, or anyone directly or indirectly employed by the Municipal Vendor or anyone for whose acts any of them may be liable, the indemnification obligation under this paragraph shall not be limited in anyway by any limitation on the amount or type of damages, compensation or benefits payable by or for the Municipal Vendor, under Workers' Compensation Acts, Disability Acts, or other Employee Benefit Acts." Subscribed and sworn to before me this ) b , 20 a 1 Person, Firm, or Corporation 8'AAJ Notary P iblic KATHY BICHSEL OFFICIAL SEAL .. Notary Public, State of Illinois My Commission Expires Apr! 123, 2023 THIS FORM IS BASED ON IRS REQUIRMENTS FOR THE SAME ESSENTIAL INFORMATION AS A W-9 RETURN TO: CITY OF GALESBURG OR FAX TO: 309-343-4765 ATTN: AIP 55 W TOMPKINS ST GALESBURG, IL 61401 The following information is needed to complete your vendor file and to comply with IRS requirements. Please fill out this form as completely as possible to ensure proper payment to you. Please return completed form as soon as possible to The City of Galesburg at the above address or fax number. Please call 309-345-3674 with any questions. BUSINESS NAME: AtCo Masonry LLC INDIVIDUAL NAME: (for Sole Proprietors as appears on Social Security Card) BUSINESS ADDRESS: 9998 North 2200th Rd CITY, STATE, ZIP: Sciota IL 61475 YOUR TAXPAYER IDENTIFICATION NUMBER: 86-2585769 (FEIN or business tax ID. No.) OR, YOUR SOCIAL SECURITY NUMBER: If using SSN, enter the name on the card above as individual Name.) PLEASE CHECK APPROPRIATE BOX: ®IndividuallSole Proprietor Corporation Partnership Other YOUR COMPANY PROVIDES: F-11.egal Services ElServices ElMaterials Other ARE YOU SUBJECT TO BACKUP WITHHOLDING? Yes ®No PERSON TO CONTACT: Derek Cooper PHONE NUMBER: 309.536.1505 UNDER PENALTY OF PERJURY, I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS CORRECT AND COMPLETE. Signature Ownerl Estimator Title 11/1/21 Date