Contract (PO) Number:

Release Number: 4

Specification Number:

Name of Contractor: OLD VETERANS CONSTRUcnON, INC

City Department: DEPT OF GENERAL SERVICES

Title of Contract: JOB ORDER CONTRACf REHABILIT A nON OF CITY FACILITIES

Dollar Amount of Release: $33,947.19

GENERAL CONSTRUCTION - PUBLIC WORKS RELATEDRelease Description:

Procurement Services Contact Penon: BYRON WHmAKER

Vendor Number: 1036761Submission Date:

I "

CITY OF CHICAGO . .BLANKET RELEASE Original (Department)

SUBJECT TO SUBCONTRACTOR CERTIFICATIONFurnish tile supplies and/or Hrvtc:es descrIbed be'- In conformance with condl1iona set fonh her.tn and In ... after

PURCHASEORDER

RELEASENUMBER

SPECIFICATIONNUMBER

SITENAME

CERT

DELIVERYDATE

-

PAGENUMBER

RELEASEDATE

07/12/2005 8888 4 26799

VENDORNUMBER

1036761 1

DELIVER TO: 38-038 ORDERED FROM:

:JBlANKET RELEASE

THIS SIGNED RELEASE IS YOUR AUTHORITY TO FURNISH THE SPECIFIED SUPPLIES AND /OR SERVICES IN ACCORDANCEWITH THE TERMS AND CONDITIONS OF THE BlANKET AGREEMENT NUMBER: 8866

THIS PURCHASE IS FOR DEPARTMENT: 38 - DEPT OF GENERAL SERVICES

SUBMIT THE ORIGINAL INVOICE TO:

ShipLIne

1

POLIne

1

COMMODITY INFORMATION QUANTITY

96842 33,947.19

GENERAL CONSTRUCTION - PUBLIC WORKS RELATED

UOMUSD

JV5.011.E; INSTALl S- COMPOUND WATER METER; L-4-021; BA TCHMAN; CIP130-02-0338

Dlat BFY FUND COST CTR APPR ACCNT ACTV PROJECT RPT CAT GENRL FUTR1 005 0486 0382005 6186 220540 0000 48078151 00000o 00000 0000

2 004 0403 0382005 8044 220540 0000 40035151 OO(XKX) 00000 0000

3 003 0403 0382005 8050 220540 0000 40041151 00000o 00000 0000

SHIPMENT TOTAL._.~:

18,486.79

12,571.902,888.50

_33,847.11

1

RELEASE TOTAL: 33,947.19

APPROVAL: -~ ~~ ,1\4ft6SIGNAfu~- ~- . - . DATE-

'-'"

-Payment on IIIi8 order will be made upon receipt of.n origin.. vendor Invoice form referencing this order.

Submit the origlNI Invoice to the deP8nment referenced .bove.M.rk .11 p.ck8ges and P8pers wnh the purch8.e number.

Any dellveriea containing overshlpments will be reflected unle.. otherwise authorized in this purchase.TIlle purchase Ie .ubjeet to the City of Chicago General Cond~n. for Supplies. Work, or Profesajonal Con.ultlng ServIces; SpecIal Cond~. Di8dO8ure

Ownership, Acceptance Page, a. applicable, which are attached hereto or Incorpor.ted hefeIn by reference.

..

City of ChicagoDepartment of General Services30 North LaSalle StreetChicago, IL 60602

A. Definitions and Disclosure Reauirements1.As used herein, U1e term "Contracto(' means 8 person or entity who has any contract 1- wilt! the City of Chicego.2. PulSant 10 Executive Order 97-1 ,every dty contract and lease must be accompanied by a disdosure statement

Providing certain information and attorneys, lobbyists, ~untants, ~, subcontractors ,and OCher ~Whom the contraclor has retained or expects to retain wilt! respect 10 U1e contract or lease. In particular, U1e contadormust disdose the name of each such person, his or hef business address, the nature of tie relationship,and theamount of '- peid or estimated 10 be paid.

3. The Contractor is not required 10 disclose employees who are paid solely thI'ough the Contractor's regular payrdl.4."lobbyisf' means any person (a) who for compensation or on behalf of any person other than himself ufxieItakes 10

influence any legislative or administration action, or (b) any pert or whose duties as an employee of another~ u~ to inftuence any legislative or administrative action.

B. Certification

Contractor hereby certifies as follows:

1. This Di8dO&ure relates to the following transaction:

PIoject name: JV5-011.E Marine Safety Statk)n Compound Water Meter

SpecificaOOn,1oan or other identifying number: 001

2. Narne of Contrador: Old Veteran Construction

3. EACH AND EVERY attorney, ~ aooountant,oonsuMant. subcontractor, or other person retaWIed or antk:ipetedto be retained by the Contractor wilt! resped to or in ~ wilt! the aJntract or lease Is listed b8tON(attach ad<Mticx\al pages if ~:

10942 S Halsted StreetChicago, 0 60628

TOL TEC Plumbing Co~ 4366 W Ogden Ave MBE ~ $28.598.00 Est.: Chicago, IL, 60623CHECK HERE IF NO SUCH PERSONS HAVE BEEN RETAINED OR ARE ANTICIPATED TO BE RETAINED.

4. The Contraclor Understands and agrees that the city may rely on the information provided hereWI and that ~any false inoomp/ete or inaa:urance information shall constitute default under the oontrad and may result intermination of the contrad or lease5. The Contt8ck>r underItands and egress that in any case in which the Contrador is unceftain whether a disdosure is ~ under tie ~ Older, .". ~ ~ eithef

ask the city whether disdoswe Is required or make the disck)sure.

Under the PenaHies of perjury, I certify that I am authorized to execute this Disclosure on behalf of the ConlradOl that the informam di8doaed ~n is Wue 8nd ~, and that no

t,Q-.-O5.,Date

(Jt-I\""L~Title

":JdL- -j; >~~~::~ ~ ,

Name (Type or Print)

Disdosure Statement

June 08 2005

Ms. Mary A. ~1n8rim ChIef Procur.-nent OfficerDepa~ of ProcUf8m8nt Serva.City Hall, Room 403121 NorU1l8SaIe StJ88tChicago, II ~

City of ChicagoRichard M. Daley, Mayor

Department of GeaeraJ Senices

Michi E. Pefta

~ Catherine MellonJOC Manage'

Atbt:

Suite 37003ONri~ S~Qaicago, DJinois ~2-2S86(312) 742-3124(312) 744-9883 (FAX)

hnp://www .cityCJibica&O.CXI

JOC Project Number:

Project Title:

Address:

Re: JV5.011.E I L-4..021

CMSS - Room Finishes - Water Meter

250NorthBre8kwat8rAcx:ess

Estimated Cost:

Specification Number:

Funding Source:

35,000.00

26799

05-0486-38-2005-61.~78-151

Dear Ms. c.I1)8ey:

We request that the above referenced project be contracted under the JobOrder Contr8ding (JOC) Method. Abchment A ~ the scope of worXand the appropriaten888 for I8ing JOC for tIW projed.

Please direct all .mnlcalinquiries to Project Manager Mike Batchman at (312)744-1107 and.. cAher inquil'-. to Stad-Rae Bixler at 744-1636.

If you concur with our recom~ndation. please sign below and return a copy for

our files.

APPROVED: 6.e;$-- -Interim Chief ProaJr*"8nt Ofticer

JdVI PI8ZMIt 9l--,AppVV8d:

~ Mc(J88ft . ~I.

IUILDJlfG CHICAGO TOGnDa

The Department of General Services

JOC Approval Letter

Utilizing JOC For CItY Construction ProlectsMarine Safety Station

250 North Breakwater Access

Project No: JV5-O11.E

For all Proposed JOC Projects. Please complete Items 1 and 2 below. As appropriate. Complete items 3.4 and 5. Attachto MOA (JOC Approval letter)

Please describe the major features of this project.Provide & install an 8' compound water meter as required by the Department of Water.

2. Please explain why this project could not be bid using the city's traditional bid process and the need to useJOC Procurement system.

3.

This scope was not included in the work assigned to the trades as part of the joint effort between JOC & the DGSTrades.

If the project is a one trade project, please provide additional explanation of why it would not be in the city'sbest Interest to do the project under JOC.

4.

This is a multi -trade project requiring the use of a plumber. equipment operator & laborer.

If it is anticipated that over 25% of the project will consist of Non-preprlced items, please provide anexplanation on why JOC should be used.

No Non-prepriced items will be used.

5. If some elements of the proposed JOC Project scope of work are covered by city term agreements, theseelements should be removed from the JOC Project.

There is no city term agreement in place to complete this task.

1

DEPARTMENT OF GENERAL SERVICESBureau of Architecture, Engineering & Construction Management

JOB ORDER CONTRACT (JOC)PRE-CONSTRUCTION FUNDING APPROVAL

Date: June 08, 2005Chicago Police DepartmentUser Dept

Phone: (312) 744-1107Mike BatchmanOriginator:

JV5-O11.E I L-4-021Project Number:

CMSS - Room Finishes - Water MeterProject Name:

Provide & install an 8" compound water meter.Project Scope:

250 North Breakwater AccessLocation/Address:

This work has been requested as a water permit I fire supression systemrequirement

Justification;

$35,000.00Est Project Budget:

130-02-0338CIP#:

Funding Strips: 05-0486-38-2005-6186-220000-48078-151

,. Date: ~ hr- .Funding Verified By:

Can this request be completed by one of the following:

YesYesYes

NoNoNo

12

3

In-House TradesTerm ContractCompetitive Bid ~

~'-' -

Date

John J. Plezbert, First missioner Date

-- b' --a-err

If No, for any of the above please explain:

1. This work was not considered ito be performed by the trades due to the demand from the remaining work tobe performed.2. There is no term agreement to perform this work.3. This work was originally placed for competative bid & was assigned to DGS & JOC for completion.~

APPROVED: