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6.D. - Page 67 of 170 Request for Qualifications: General Park Building Construction, Retrofit, Maintenance, and/or Repairs EXHIBIT A LW -111) LWO — JCC NON-COVERAGE/EXEMPTION APPLICATION OCC DETERMINATION/APPROVAL REQUIRED This application for non-coveragelexemption must be submitted bythe Contractor along with its bid or proposal to the AWARDING DEPARTMENT. Awarding Departments may also apply for an exemption for OCC approval. INCOMPLETE SUBMISSIONS WILL BE RETURNED. Los Angeles Administrative Code 40.37, the Lining Mage Ordinance (LWO), presumes all City contractors (including service contractors, subcontractors, financial assistance redpnents, lessees, licensees, sublessees and sublicensees) are sublject tom the LWO unless an exemption avvlies. COKTRACTOR INFORMATION: 1. Company Name: Phone Number_ 2. Company Address: 3. Are you a Subcontractor? ❑Yes ❑ No I€ YES, state the name of your Prime Contractor 4,Type of Service Provided: _ - - NON -COVERAGE INFORMATION: TO HE REQUESTED 13Y AWAFMING DEPARTMENTS OR CONTRACTORS REQUEST FOR NON -COVERAGE DETERMINATION SUPPORTING DOCUMENTATION REQUIRED Per Section 10.37.13 of the LWO, contractors may A detailed memorandum explaining the basis of the request. request a determination of non -coverage on any basis which may include, but is not iunited to: the terms of a city allowed by this article, including, but not rimmed to: non- financial assistance agreement, purpose of the contract, coverage, for failure to satisfy definition of 'City LOnianoial lvcat5on. and work performed. OCC may request fimther assistance necipienf, 'public leaseftense', or ''service in€loHnation to issue a determination. contracr. EXEMPTION INFORMATION: CHECK OFF ONE BOX BELOW THAT BEST DESCI MES THE TYPE OF EXEMPTION YOU ARE APPLYING FOR AND ATTACH THE SUPPORTING DOCUMENTATION LISTED ON THE BIGHT: TO BE REQUESIFED 13Y AWARDING DEPARTMENTS ONLY EXEMPTION SUPPORTING DOCUMENTATION REQUIRED ❑ Grant Funded Services, provided that the grant funding Provide a copy of grant -funding agencys determination to the OCC. agency indicates in writing than the provisions of the Ordinances should not apply. TO BE REQUESTED BY CONTRACTORS ONLY EXEMPTION SUPPORTING DOCUMENTATION REQUIRED Lj Collective bargaining agreement with supersession A copy of ttie CBA with the superseding language ol6early language - (LAAC 10.37.12): Contractors Who are party to a marked collective bargaining agreement (CI3A) +whiich contains OR specific language indicating that the CBA will supersede the A letter from the union stating that the union has agreed in LWO may receive an exemption as to the employees allow the CBA to supersede the LWO. ed under the CBA. cupational license required - (LAIC 40.37.i1[f)): Only A listing of flue employees required to possess occupatnonail dividual employees who are required to possess an [enxe.pt. licenses to perform services to or for the City Occupational license to provide services to or for the City are AND Copies of each of these ernployees7 occupational licenses. By signing, the contractor certifies under penalty of perjury under the laws of the State of Cali€nrnia that the information submitted In support of this application is true and correct to the best of the contrador's knowledge. Print Name of Person (Contractor) Comtoietirrg This Farm Gkwtature of Person (Contractor) Completing This Farm Title Phone # Date ANY DETERMI NATIOWAPPROVAL IS APPLICABLE ONLYTO THE LISTED CONTRACTOR FROM THE LWO DLFJ%Tt-E PERFORMANCE OF THIS CONTRACT_ A SUBCONTRACTOR PERFORMING WORK ON THIS CONTRACT IS NOT EXEMPT UNLESS THE OFFICE OF CONTRACT COMPLIANCE HAS APPROVED A SEPARATE APPLICATION FOR THE INDIVIDUAL SUBCONTRACTOR AWA.RDIING DEPARTMENT USE ONLY: Dept: Dept Contact: Contact Phone: Contract #: OCC USE ONLY: Approved l Not Approved— Reason: By OCC Analyst: Date: Form OCCILW-10, Rev. 11109 OFFICE CAF CONTRACT COMPLIANCE, EEOE SECTION: (2131 W-2925 IMPORTANT — RESPONDERS MUST SUBMIT ALL REQUIRED FORMS (COMPLETELY FILLED OUT) BY RFQ SUBMITTAL DEADLINE. Page 61 of 103 150