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6.D. - Page 69 of 170 <br />Request for Qualifications: <br />General Park Building Construction, Retrofit, Maintenance, and/or Repairs <br />EXHIBIT B <br />Revised February 2014 LasAnon Madpaa Code $ 4SA"Hl <br />IMPORTANT – RESPONDERS MUST SUBMIT ALL REQUIRED FORMS (COMPLETELY FILLED OUT) BY RFQ <br />SUBMITTAL DEADLINE. <br />Page 63 of 103 <br />152 <br />2city Ethics Spring Shvsg amaa � <br />� N Street <br />dder Certiffeeffon <br />ad -2 <br />City H�l-24'It� t=torr <br />Los Angeles. CASDDI2 Form 50 <br />Mad1 Stcp 129 <br />(21315T8�79611 <br />This frariaT must be szdwn ed Eio Etre awarcUng army %Wth ymw third <br />oripr©,posaf kr the contract noted below Pdea4se w de deglbdy_ <br />Clriginal fi in,8 El Amended fining (original sWned on last amendment sWned on l <br />BidlContractfBAVNNumber_ <br />Awarding Auttwrfy tt)epartmentk. <br />CITY OF L05 AN6EL65 DEPT: of E@RERV0N N D008,KS <br />-1 <br />Name of Bidder_ <br />—711 <br />Phar e. <br />%%E PUP.IC RE5TR©oln t7orr7P#NY <br />gg8� S�g'ao�o <br />Address. <br />.J9 0 S! ass P A -R KGugY MINDEN /111/ Ff 9 y a 3 <br />Email - <br />CHUCK @ P(16LlG8ESi P)OO ►ComP(+AIY. Goo <br />CERTIFICATION <br />I certify the following on grays owes /behalf or on behalf of the entity narned abave, which 1 am authorized to represent <br />A. 1 am a person or entity that is applying for a contract with the City of Los Angeles. <br />B_ The conlract for which 1 am applying is an agreement for one of the following: <br />1. The performance of work or service tot the City or the public; <br />2- The provision of goods, equiF K rrrateriais, orsuppltes; <br />3- Receipt of a grant of Cfty financial for economic development or job growth, as further described <br />in Los Angeles Administrative Code § 10_40.1(h)- or <br />4- A public lease or license of City property where both of the following apply, as further described in Los <br />Angeles Administrative Code § 10.37.1(l): <br />a. 1 provide services on the City property through employees, sublessees, subl'icensees, contractem, or <br />subcontraelnM and those services: <br />L Are provided on premises that are visited frequently by substantial numbers of the ;putbH.= or <br />ii. Could be provided by City employees if the awarding authority had the resources, or <br />in- Further the proprietary interests of the City, as determined in writing by the awarding authority_ <br />b- I am not eligible for ea pil3tion from the City's living wage ordinance, as eligibility is described in Los <br />Angeles Administrative Code § 10-37-1(I)(b). <br />C. The value and duration of the contract forwhich I am applying is one of the f61110V ng: <br />1. For goods or services conhacts--.sa value of more than $25,000 and a term of at least three months <br />2. For financial assistance contracts --a value of at least $1110,000 and a term of any durabort; or <br />3. For construction contracts, public leases, or licenses—any value and duration. <br />D. I acknowledge and agree to conV1y With the disclosure requirements and prohibitions established in the Los <br />Angeles ir9unielpal Lobbying Ordinance if I qualify as a lobbying entity under Los Angeles Municipal Code § <br />48.02. <br />I certify under penalty of perjury under the laws of the C Ky of Los Angeles and the estate of California that the <br />information in "s form is true and complete. <br />Date: Signature- <br />ignature.Name:_L <br />Name:- �. KAUFMA4 <br />Title: P8 65 i D 5N T <br />Revised February 2014 LasAnon Madpaa Code $ 4SA"Hl <br />IMPORTANT – RESPONDERS MUST SUBMIT ALL REQUIRED FORMS (COMPLETELY FILLED OUT) BY RFQ <br />SUBMITTAL DEADLINE. <br />Page 63 of 103 <br />152 <br />