Michigan Department PROPOSAL CERTIFICATION Page 1 of 2 Of ...

Michigan Department Of Transportation 0364 (02/13)

PROPOSAL CERTIFICATION

Page 1 of 2

A local agency uses this form when it requests MDOT approval to "locally let" its enhancement funded project. Submit this form and completed MDOT Form 0365, "REQUEST TO ADVERTISE", to MDOT Local Agency Programs (LAP), with the final plans, bid proposal book, and construction cost estimate.

ELIGIBLE AGENCY (County, City, or Village)

CONTROL SECTION

MDOT JOB NO.

TRANSPORTATION ALTERNATIVE GRANT NUMBER

I ___________________________, the project engineer, certify the following with respect to the plans, specifications, and construction cost estimate for this project:

ENGINEER'S ESTIMATE FOR THIS PROJECT IS:

MINIMUM CONTRACTOR PREQUALIFICATION IS:

THE BID BOND FOR THIS PROJECT WILL BE:

STARTING DATE

COMPLETION DATE

THE INSURANCE FOR THIS PROJECT WILL BE IN ACCORDANCE WITH THE MDOT 2012 STANDARD SPECIFICATIONS FOR CONSTRUCTION SECTION 103.10, OR AS FOLLOWS:

IN ADDITION TO THE OWNER AND MDOT, ADDITIONAL INSURANCE IS PROVIDED FOR:

PLANS FOR THE ABOVE PROJECT HAVE BEEN PREPARED IN ACCORDANCE WITH THE FOLLOWING: (Check as many as apply)

Current AASHTO "A Policy on Geometric Design of Highways and Streets" (green book) Current AASHTO Guide for the Development of Bicycle Facilities Secretary of Interior Standards for Rehabilitation MDOT LAP Guidance for Geometrics MDOT Landscape Guides Other ? Specify ___________________________________________________________________

Yes No

N/A The project incorporates the MDOT 2012 Standard Specifications for Construction except as modified by special provision or supplemental specification.

The performance bond and the lien bond for this project will be 100% of the bid amount. There are railroad crossings within the limits of the project that require work. If yes: All the necessary arrangements have been made with the railroad company to accommodate this project. There are utilities affected by this project. If yes:

Work on the following utilities has been reflected in the plans and specifications _____________________. Work on the following utilities will be done but not as part of the contract ___________________________. The project has received review by the State Historical Preservation Office. (Copy of letter attached) All required DEQ and Corps of Engineers Permits have been secured. (Copies attached) An MDOT Permit to Construct in Trunkline right of way has been secured. (Copy attached) All mitigation measures required in any of the permits or resulting from any reviews have been addressed in the proposal documents.

Design exceptions have been applied for, and MDOT LAP approval has been received.

MDOT 0364 (02/13)

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The following federal required special provisions or Notice to Bidders have been included in the proposal as provided by MDOT:

Yes Non-Collusion statement

Appendix A - Prohibition of Discrimination in State Contracts

Title VI Assurance ? Appendix C

General Request for Recipients - Excerpts from USDOT Regulation 49 CFR, Part 26

Special Provision ? 23 CFR CH.1 P 4.230, SUBPT..a, APP. A

Required Contract Provisions - Federal ?Aid Construction Contracts ? FHWA 1273 Notice to Bidders - Certified Payroll Notice to Bidders - Report Forms Notice of Requirement for Affirmative Action - Executive Order 11246 Davis Bacon Required Wage Rates

The following Supplemental Specifications, Special Provisions, Permits, or Notice to Bidders have been included in the Proposal:

Yes No

N/A Progress Clause Maintenance of Traffic Special Bonding Provision Special Provision Taxes Notice to Bidders - Insurance ? Named Insureds

Notice to Bidders ? Contact Information Special Notice - Insurance - Certificates of Insurance Utility Coordination Clause

Coordination Clause, if applicable Applicable Frequently Used Special Provisions (2012) Applicable Supplemental Specifications for 2012 Standard Specifications, including Errata Applicable Notices to Bidders (2012) MDEQ Permits MDOT Permit - for work in State Trunkline Right of Way only Permits issued by other agencies, departments, or municipalities.

Division 1 ? General Provisions of the MDOT 2012 Standard Specifications for Construction apply to this project and shall not be modified, revised, or superseded without written concurrence from MDOT.

The Signed and Sealed Plans, the proposal, and the engineer's estimate are a part of this certification and are included herewith.

SIGNATURE OF LICENSED REGISTERED PROFESSIONAL ENGINEER OR ARCHITECT

TYPED NAME

REGISTRATION NUMBER

DATE

EXPIRATION DATE

LICENSED REGISTERED PROFESSIONAL ENGINEER OR ARCHITECT SEAL

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