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CITY OF YADA PUBLIC WORKS DEPARTMENT - ENGINEERING PHONE: [PHONE REDACTED] The following is required for your City of Arvada Municipal General Contractor's License: If all forms are not completely filled out or correct, your application packet will be returned. Please allow up to 1 week for processing. 1. Application Form (enclosed)- Please fill out completely a. Application must be printed or typed - Applications that are not legible will be returned. b. Make sure your company name is identical on all documents. 2. Affidavit form ( enclosed) a. Please fill out either the top portion or the bottom portion ONLY, not both. 3. $20,000 Bond Form (enclosed) a. All blank lines must be filled out. The amount of the bond MUST be $20,000.00 b. The expiration date must be ONE year from the date of the bond issuance. c. The bonding company seal is REQUIRED as well as the power of attorney. d. An authorized signer from your company must sign the bond along with the bonding company agent's signature. e. The Bond must be on the original City of Arvada Bond form. 4. Certificate of Insurance ( example enclosed) a. Insurance must be on an acceptable form established by the Risk Management division of the City of Arvada. See attached examples. b. General aggregate limit shall be unlimited or at least $2,000,000.00; The limit for each occurrence shall be not less than $1,000,000.00 c. The City of Arvada must be included as additionally insured. d. Auto liability is not required unless a City Bid Project is being done (If required $1,000,000.00 is the minimum) e. Typed or printed name and signature of an authorized insurance agent is required; also date of issuance of certificate. 5. Statutory Workmen's Compensation (If you do not carry workmen's compensation you must fill out a certificate of exemption form). The Engineering Code of Standards and Specifications must be easily accessed on the job site at all times. Please refer to our website at code/ engineering-code-of-standards-and-specifications Any questions, please call (720)898-7640 or email [EMAIL REDACTED] Revision 02/2021 8101 RALSTON ROAD ARVADA, COLORADO 80002 ---PAGE BREAK--- PUBLIC WORKS DEPARTMENT - ENGINEERING PHONE: [PHONE REDACTED] MUNICIPAL GENERAL CONTRACTOR'S LICENSE APPLICATION PLEASE PRINT CLEARLY In accordance with the "Engineering Code of Standards and Specifications for Design and Construction of Public Improvements" and Chapter 78, Article II of the Code of the City of Arvada, current copy of which (I/WE) have obtained, read and understand, (I/We) DBA (an Individual_, a Partner-ship a Corporation a Limited Liability Corporation ) under the name of: Business Name: Email Address: Mailing Address: City State Zip____ _ 24 Hr. Emergency Number______ _ ITEMS INCLUDED WITH THIS APPLICATION ARE: 1) Affidavit Form 2) Statutory Workmen's Compensation Insurance 3) Certificate of Liability and Property Damage Insurance on "Accord" Form or approved equal 4) $20,000 Bond on City of Arvada form License Fee $210.00 to be paid by phone, in person or mailed This application is for a: New License Renewal Applicant has been in business for years, (has never (has* ) had a license denied, suspended or revoked and (is presently (has been ) licensed to perform this type of work with the following municipalities: *provide a statement of explanation with license application. The following persons are familiar with the applicant's work and may be contacted as references: NAME COMPANY ADDRESS PHONE The following individuals, partners or corporate officers are authorized to sign for permits under this license: The undersigned hereby certifies that the information contained herein is true, under penalty of license denial, suspension, revocation and/or civil/criminal penalties. The undersigned further agrees that, if granted a license to perform work in the City of Arvada, the licensee will have in their possession at work sites at all times, a current copy of the City of Arvada Engineering Code of Standards and Specifications. The licensee shall comply with the regulations contained therein, and shall accept the responsibilities thereto as set forth in the Arvada Municipal Code and the current Engineering Code of Standards and Specifications. Signed by _ Title Date Please send applications to [EMAIL REDACTED] License Application Form Jan 2023 8101 RALSTON ROAD ARVADA, COLORADO 80002 ---PAGE BREAK--- AFFIDAVIT FOR LAWFUL PRESENCE VERIFICATION Because of Colorado House Bill 06S-1023 (C.R.S. 24-76.5-103), this affidavit is MANDATORY and must be submitted along with a copy of one of the accepted forms of identification to prove lawful presence in the United States. Colorado law now requires that the City of Arvada verify all natural persons 18 years or older or sole proprietors who are applying for a public benefit are lawfully present in the United States prior to receiving the public benefit. A public benefit includes the application or a renewal of a grant, loan, contract, and professional or commercial licenses provided by an agency of the state or local government. FOR CORPORATIONS/PARTNERSHIPS/COMPANIES ETC. ONLY The applicant, for whom I am authorized to sign, is NOT a "natural person" or "sole proprietorship," but a corporation, partnership, company or other similar entity. HB 06S-1023 is not applicable. I understand this sworn statement is required because the applicant has applied for a "Public Benefit." I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the laws of Colorado. Printed Name and Title of Applicant's Representative Signature of Applicant's Representative Date Name of Business OR FOR "NATURAL PERSONS" OR SOLE PROPRIETORS ONLY I am a "natural person" or a "sole proprietorship," NOT a corporation, partnership, company or other similar entity and MUST complete this affidavit and submit it with the required documentation. 1. I, _ swear or affirm under penalty of perjury _ under the laws of the State of Colorado that ( check one): D I am a United States citizen; or D I am a Permanent Resident of the United States; or D I am lawfully present in the United States pursuant to Federal law. 2. I understand this sworn statement is required by law because I have applied for a "Public Benefit." 3. I understand state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. 4. I acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the laws of Colorado. 5. I have attached a copy of one of the acceptable documents provided by the state of Colorado and I presented it to the agency as proof of identification that I am at least 18 years of age and I am lawfully in the United States. Applicant's Printed Name Applicant's Signature Date Name of Business (If applicable) Revised 08/01/07 SIGN SIGN ---PAGE BREAK--- ACCEPTED FORMS OF IDENTIFICATION TO PROVE LAWFUL PRESENCE IN THE UNITED STATES: A valid Colorado driver license (includes only a current driver license; or valid Colorado identification card , or U.S. military card or military dependent's identification card, or U.S. Coast Guard Merchant Mariner Card, or Native American Tribal Document. Certificate verifying naturalized status issued by an authorized agency of the United States bearing Applicant's intact photograph impressed with the raised embossed seal of the issuing agency; Certificate verifying United States citizenship issued by an authorized agency of the United States bearing Applicant's intact photograph impressed with the raised embossed seal of the issuing agency; Valid driver license or ID card bearing applicant's photograph issued by a lawful presence state. All states are lawful presence states including the District of Columbia with the exception of: Hawaii, Illinois, Maryland, Nebraska, New Mexico, Utah, and Washington. If on the face of the license or ID card presented it says that it is an enhanced driver license or ID card, and then it is to be accepted as a lawful presence document. Valid immigration documents demonstrating Lawful Presence and verified through the Systematic Alien Verification for Entitlements, administered by the United States Citizenship and Immigration Services of the Department of Homeland Security. Valid immigration documents are as follows: o Unexpired Foreign Passport bearing an unexpired "Processed for 1-551" stamp or with an attached unexpired "Temporary 1-551" visa. o Unexpired Foreign Passport accompanied by an "1-94" indicating a specific future "until" date. o "1-94" with refugee or asylum status. o Unexpired "Resident Alien" card, "Permanent Resident" card, "Temporary Resident" card, or "Employment Authorization" card. Waiver Process If you cannot produce any documentation necessary to prove lawful presence, you may request a waiver, (Form DR 4678). The waiver is available for individuals who: • Due to chronic health or medical condition, lack sufficient mobility to appear in person to apply for a Colorado Driver license or Colorado identification card, or • Due to lack of a permanent physical address in Colorado, do not qualify for a Colorado driver license or Colorado identification card, or • May lack sufficient documentation to receive a Colorado driver license or Colorado identification card. The waiver and all supporting documentation must be presented by you or a representative at a participating Colorado driver's license office, not at the City Department where you are requesting the benefit. Arvada cannot approve the benefit until the waiver process has been completed. ---PAGE BREAK--- @ CHYOfARVADA MUNICIPAL GENERAL CONTRACTOR'S LICENSE BOND NO. City of Arvada - Engineering Division 8101 Ralston Road Arvada, CO 80002 (720) 898-7640 THIS AGREEMENT made on this day of is by and between referred to as "Principal") and a Corporation, whose home office is located in (hereinafter referred to as "Surety"). RECITALS The Parties hereto recite and declare that: 1. They are held and firmly bound to the City of Arvada, State of Colorado (hereinafter referred to as "Arvada"), in the sum of TWENTY THOUSAND AND NO/100 DOLLARS ($20,000.00), in lawful money of the United States of America for the payment whereof principal and surety bind themselves, their heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by this Agreement. 2. Principal has been duly licensed as a Municipal General Contractor and is thereby entitled to perform work on general public improvements for which the Principal is qualified. 3. Principal desires to deposit this bond in lieu of separate bonds for each general public improvement (hereinafter referred to as the "Work") on which Principal works. TERMS AND CONDITIONS This obligation shall remain in full force and effect for a period of one year, unless renewed by continuation certificate signed by those authorized to validate and bind the company in the first instance with respect to suretyship, bonds, undertakings, recognizance and obligatory instruments and under the seal of said Surety. This bond will have a two year warranty period from the date on which the last public improvement was completed and accepted by Arvada. The condition of this obligation is that if: Principal, or its heirs, executors, administrators, successors, and assigns shall, for the period of this bond, properly comply with Arvada's requirements and City Code provisions; replace any and all defects arising in the Work, whether resulting from defective materials or defective workmanship; and indemnify and hold harmless Arvada against suits or claims for damages or losses which may be brought against Arvada, or any of its officials and employees, because of the Work performed under the Principal's license, then the above obligation is null and void; otherwise it will remain in full force and effect. This obligation may be canceled upon thirty (30) days written notice delivered by the Surety to Arvada relieving the Surety from any obligation for public improvements performed after the expiration of the thirty (30) day cancellation period. No Right of Action shall accrue on this bond to or for the use of or benefit to any person or corporation other than the City of Arvada. IN WITNESS THEREOF, said Principal and said Surety have executed these presents this day of (SEAL) Principal Title Surety Attorney-in-Fact 05/21 ---PAGE BREAK--- City of Arvada Risk Management Division 8101 Ralston Rd. Arvada, CO 80002 Telephone: [PHONE REDACTED] Fax: [PHONE REDACTED] Requirements when filing Acord form Certificates of Insurance Effective December 1, 2004 Improperly issued certificates will not be accepted ADDITIONAL IMPROPERLY ISSUED CERTIFICATES WILL NOT BE ACCEPTED INSURED City of Arvada must be shown as an additional insured with regard to: General Liability Products Liability Automobile Liability Liquor Liability (if applicable) Additional insured forms CG 20-12-07-98 ADDITIONAL INSURED- STATE OR POLITICAL SUBDIVISIONS - PERMITS or CG 20-26-07-04 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION should be used. Additional insured wording should read "The City of Arvada is name as an additional insured as their interest may appear with respects to the above policies. Copy of additional insured endorsement must be attached to the certificate. CANCELLATION ► THIRTY (30) days notice of cancellation, except for non-payment of premium PROVISIONS DESCRIPTION OF Please provide a Description of project to which certificate applies. OPERATIONS If Certificate is for contractor's license, please so indicate. COVERAGE, A General Liability Occurrence limit must be at least $1,000,000 LIMITS AND TERM A General & Prod/Comp Operations Aggregate must be at least $2,000,000 A Liquor Liability (if applicable) must be at least $150,000 A Auto Liability must be at least $1,000,000 A Worker Compensation at least based on statutory limits prescribed by and for the state of Colorado A Certificate must be for current policy term CARRIER Carrier must be rated B+ or better, according to Best's Rating Guide IMPROPERLY ISSUED CERTIFICATES WILL NOT BE ACCEPTED 9/21/05 Revision ---PAGE BREAK--- .1 - I DATE (MM/DD/YYYY) ACORD™ CERTIFICA IE OF LIABILITY INSURANCE r; . . ) .'PRODUCER THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ·1 · ( HOLDER. THIS CERTIFICATE DOES NOT AMEND, EX TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IN SURERS A FFORDING COVERAGE NAIC # INSURED INSURER A: ABC COMPANY INSURER B: 1 23 Str~et INSURER C: D·enver , co 80202 INSURER-0: INSURER E: - COVERAGES THE POLICIES. OF INSURANCE LI STED BELOW HAVE BEEN ISSU ED TO THE INSURED NAMED ABOV E FOR THE POLICY PERIOD IN DICATED. NOTWITHSTANDIN G " -::::Y!ReME~DJTin~ n c H 1v rn"Tc ~r.T n c n o C UMENT WIT H RESPECT T O WH ICH T HIS CERTIFICATE MAY BE ISS UED OR MAY PERTA IN, THE INS URANCE A FFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJ ECT T O A LL T HE TERMS, EXC LUSIONS AND CONDITIONS .O F SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAI D CLAIMS. INSR ADO"l POLIC Y EFFECTIVE POLICY EXPI RATION LTR NSRC TYPE OF INSURANCE POLICY NU MBER DATE IM M/DD/YY1 DATE IMM/OD/YYl . -LIM ITS - A GENERAL LIABILITY 10/01/04 10/01/05 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $300 000 PAi= i'!.if t , - CLAIMS MA DE OCCUR - MED EXP (Any one person ) $10 000 PERSONAL & ADV INJURY $1 000 000 - GENERAL AGGREGATE $2 000 000 - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2 000 000 7 ·ix7PRO- · POLICY X JECT nLOC 8 AUTOMOBILE LIABILITY ' 10/01/04 10/01/05 - COMBINED SINGLE LIMIT - ' s1,ooo,ooo X ANY AUTO (Ea accidenl) - ALL OWNED BODILY INJURY - $ SCHEDULED AUTOS (Per person) -X HIRED AUTOS ' BODILY INJURY - $ X NON-OWNED AUTOS (Per accident) - - PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY - AUTO ONLY - EA ACCIDENT $ ANY AUTO - I j OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY • EACH OCCURRENCE - . . . . - :J OCCUR CLAIMS MADE I AGGREGATE ' . $ =l DEDUCTlB_LE , $ RETENTION $ , $ C . - : . ·10/01 ,104 1 G/01/05 I WC STATU- I /OJ/;J- WORKERS COMPENSATION ANO - . X Tr,cv LIMIT.''l EMPLOYERS' LIABILITY E.L. EACH ACCIDENT 1$1 00,000 ANY PROPRIETOR/PARTNER/EXECUTIVE $100,000 OFFICER/MEMBER EXCLUDED? E.L DISEASE · EA EMPLOYEE If yes, describe under E.L. DISEASE • POLICY LIMIT $500,ooo· SPECIAL PROVISIONS below OTHER - . · · - · . - - - DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Re : Contractors License The City of Arvada is named as an additional insu-red per written agreement witl respects to the gen~~al liability per endorsement (CG 2o -2 6 - o7 - 9·s or ·CG _20-12~07-04).. Endorsement· attached· CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED ~OLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS CITY OF ARVADA NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL ENGINEERJNG DIVISION IMPOSE NO OBLIGATION OR LIABILITY OF ANY K:IND UPON THE INSURER, ITS AGENTS OR 8101 RAL.STON ROAD REPRESENTATIVES. AUT-HORIZED REPRESENTATIVE ARVADA, CO 80002 - . - - . - - · @ ACORD CORPORATION 1988 ACORD 25 (2001/08) 1 of 3 #S233092/M225441