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2023-05-23 Change Order No. 1 Extend TaxilaneMay 23, 2023 Midwest DCM Attn: Russ Cooper 8719 S. 135th Street, Ste. 100 Omaha, NE 68138 Re: Blair Municipal Airport Extend Taxilane (275'x37.5'); Blair, Nebraska NDOT Project No. BTA SA -09 / Olsson No. 022-06375 Mr. Cooper, Enclosed is an original copy of the executed contract documents with Change Order No. 1. A copy of these documents are bound in a specification book for your files. In addition, enclosed is the signed NE Tax Exempt Form 17 for your use. Sincerely, Joyce Ewing Encls. cc: Tiffany Thompson, Nebraska Department of Transportation (pdf) Phil Green, City of Blair (pdf & bound spec book) 601 P Street / Suite 200 / Lincoln, NE 68508 0 402.474.6311 / olsson.com Kow iGs:. CHANGE ORDER NO. 1 NDOT Project No. BTA — SA -009 Blair Municipal Airport Extend Taxilane (275'x 37.5') Owner: Blair Airport Authority Attn: Rod Storm 218 South 16th Street Blair, Nebraska 68008 Contractor: Midwest DCM Attn: Russ Cooper 8719 S. 135th Street, Ste. 100 Omaha, Nebraska 68138 i II Olsson Project 022-06375 The above-named Contractor agrees to make the following change(s) in the plans and/or specifications for the above -designated project: Description of change to be made: a. Update the contract to negotiated unit prices for the following items. i. Item No. 3 — Construction Staking and Surveying ii. Item No. 6 — 8" Concrete Pavement, 4713-4,000 b. Field construction acceptance testing will be completed by City/Engineer (compaction testing for subgrade and aggregate and concrete samples and strength testing). All other testing and submittals remain contractor requirement (mix design, material submittal, etc). 2. Reason for ordering change: a. During Bid evaluations, bid items 3 and 6 were negotiated under the single bid procedures. b. Elimination of duplication of personnel on-site for testing needs. City/Engineer on-site construction observer will complete field testing. 3. Settlement for the cost of the above change is to be made as follows: Item Spec Description Qty Unit Negotiated Negotiated No. No. Unit Price Extension 3 NDOT- Construction Staking and 1 LS $4,797.50 $4,797.50 114 Surveying 6 NDOT- 8" Concrete Pavement, 47B- 1,150 SY $114.35 $131,502.50 603 4,000 Page 1 of 2 4. Summary of Costs Original Contract Amount $230,372.00 Net Decrease of this Change Order ($23,000.00) Total Increase/Decrease of all previous Change Orders $0.00 Total Decrease of all Change Orders to date ($23,000.00) Total New Estimated Contract Costs $207,372.00 5. This Summary of Costs only reflects the Base Bid items. The Blair Airport Authority has elected to not award the Alternate No. 1. 6. This change increases the Base Bid contract time by 5 working days (WD) - (25 WD total). Recommended by: -- Project Engineer %' 2023 Olsson Represe ta�ve Title Date Approved by: Contractor's Autho ized Repr entative Accepted by: Title Owner's Authorized Representative Title NOTE: This change order is not effective until approved in writing by NDOT for state projects. Distribution: Sponsor, Contractor, NDOT, Engineer Page 2 of 2 6'-_._ l lf' 2023 Date :? 1 C. 2023 Date �A� Good Life, Great Service, Purchasing Agent Appointment and Delegation of Authority for Sales and Use Tax FORM 17 DEPARTMENT OF REVENUE Section A — Purchasing Agent Appointment Name and Address of Contractor Name and Address of Exempt Governmental Unit or Exempt Organization Name Midwest DCM Name Blair Airport Authority Street or Other Mailing Address 8719 S. 135th Street, Ste. 100 Street or Other Mailing Address 218 South 16th Street City State Zip Code Omaha NE 68138 City State Zip Code Blair NE 68008 Name and Location of Project Appointment Information Name Blair Executive Airport Effective Date (See instructions) 5/1m ( uL3 Street Address 2735 NE -133 Expiration Date 1/31/2024 City State zip code NeorasKa txempuon Numoer ttxempt vrganizauons vmyf Blair NE 68008 Provide the contract name, number, and a description of the project. Blair Airport Authority; BTA SA -09; Blair, Nebraska The undersigned governmental unit or exempt organization appoints the above-named contractor and the contractor's delegated subcontractors as Its agent to purchase and pay for building materials that will be annexed to real estate by them Into the tax exempt construction project Identified above. sign . -� O 6WKI C,6, T{4StA-" - //�/z3 here uthorized Signature of Exempt Governmental Unit r xe ganization Titles—Date Section B — Delegation of Contractor's Authority A contractor can delegate its authority to its subcontractor. Name and Address of Subcontractor Delegation Information for the Project Identified in Section A Name Effective Date Street or Other Mailing Address Expiration Date City State Zip Code i Portion of Project The undersigned contractor hereby delegates authority to the above-named subcontractor to act as the purchasing agent of the named governmental unit or exempt nonprofit organization. sign here Signature of Contractor or Authorized Representative Title Date Name and Address of Subcontractor Delegation Information for the Project Identified in Section A Name Effective Dale Street or Other Mailing Address Expiration Date City State Zip Code Portion of Project The undersigned contractor hereby delegates authority to the above-named subcontractor to act as the purchasing agent of the named governmental unit or exempt nonprofit organization, sign here Signature of Subcontractor or Authorized Representative Title Date Name and Address of Subcontractor Delegation Information for the Project Identified in Section A Name Effective Date Street or Other Mailing Address Expiration Date City State Zip Code Portion of Project The undersigned contractor hereby delegates authority to the above-named subcontractor to act as the purchasing agent of the named governmental unit or exempt nonprofit organization. sign here Signature of Subcontractor or Authorized Representative Title Date revenue.nebraska.gov, 800-742-7474 (NE and IA) 402-471-5729 6-139.1970 Rev. 11.2018 Supersedes 6-139-1970 Rev, 4-2009 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 t b 1 €N ��°hh �U�,Y i CONTRACT THIS CONTRACT AND AGREEMENT, made and entered into by and between the Blair Airport Authority of Blair, Nebraska, hereinafter referred to as "Owner" and Midwest DCM of Omaha, Nebraska, hereinafter referred to as "Contractor". WITNESSETH: That the Contractor, for and in consideration of the sum of $230,372.00 (Base Bid) payable as set forth in the specifications constituting a part of this contract, hereby agrees to perform in accordance with the plans, specifications, and special provisions, the various items of work also identified as NDOT Project No, BTA SA -09, as follows: being items numbered Base Bid: 1-6, as shown in the schedule of prices bid in the attached proposal, which is a part of this contract. That it is mutually understood and agreed by the parties hereto that the Contract Documents consist of the following: this Agreement, Notice to Bidders, Instructions to Bidders, Proposal, all issued Addenda, Payment Bond, Performance Bond, General Provisions, Special Provisions, Supplementary Provisions, Wage Rate Determinations, Plans, Technical Specifications, Insurance certificates, documents incorporated by reference, documents incorporated by attachment, and all OWNER authorized change orders issued subsequent to the date of this agreement. All documents comprising the Contract Documents are complementary to one another and together establish the complete terms, conditions and obligations of the Contractor. All said Contract Documents are incorporated by reference into the Contract Agreement as if fully rewritten herein or attached thereto. That the Contractor expressly warrants that 1) no third person has been employed to solicit or obtain this contract on the Contractor's behalf, or to cause or procure the same to be obtained upon compensation in any way contingent, in whole or in part, upon such procurement, 2) the Contractor has not paid, or promised or agreed to pay, to any third person in consideration of such procurement, or in compensation for services in connection herewith, any brokerage, commission, or percentage upon the amount to be received by the Contractor hereunder, 3) the Contractor has not, in estimating the contract price, included any sum by reason of any such brokerage, commission or percentage; and 4) all moneys payable hereunder are free from obligation of any other person for services rendered, or supposed to have been rendered, in the procurement of this contract. The Contractor further agrees that any breach of this warrant shall constitute adequate cause for the annulment of this contract by the Owner, and that the Owner may retain for its own use, from any sums due or to become due hereunder, an amount equal to any brokerage, commission, or percentage, so paid or agreed to be paid. That the Contractor further agrees to pay all laborers and mechanics for labor performed and pay for all material and equipment used or rented in performing the contract, and to pay to the Unemployment Compensation Fund of the State of Nebraska the unemployment contributions and interest due under provisions of the Nebraska Employment Security Law on wages paid to individuals employed in the performance of this contract. That the Contractor further agrees to supervise and direct the work competently and with such skill and expertise as is necessary to perform the work in accordance with this contract. The Contractor shall be solely responsible for the means, methods, techniques, sequences and procedures of construction and for initiating, maintaining and supervising all safety precautions and programs in connection with the work. The Contractor shall perform the work in accordance with the laws of the State of Nebraska. That in consideration of the foregoing, the Owner hereby agrees to pay the Contractor promptly the amounts set forth herein, subject to the conditions set forth in this contract, or any part thereof, as herein described, Olsson C-1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 It is further expressly understood and agreed that time is of the essence to this contract and that failure to complete the work before the expiration of the time allowance fixed in this contract would cause loss and expense to the Owner and such loss and expense would be uncertain in itself and unsusceptible of certain computation. Therefore, the Contractor expressly agrees and promises to pay as reasonable liquidated damages such liquidated damages as are provided for in this contract. It is further understood and agreed that the Owner shall have the right to deduct from any moneys due to the Contractor the amount of said liquidated damages; or the Owner shall have the right to recover such liquidated damages from the Contractor, from the surety or from both; or the Owner may deduct part of such liquidated damages as are owing and recover the balance from the Contractor, the surety or both. It is further understood and agreed that the Contractor shall not do any work or furnish any materials not covered and authorized by this contract, unless ordered in writing by the Engineer. Any such work which may be done or any such materials which may be furnished by the Contractor without such written order first being given, shall be at the Contractor's own risk, cost and expense; and the Contractor hereby covenants and agrees that no claim for compensation shall be made for any work so done or any materials so furnished. The Contractor understands and agrees that all certifications made by the Contractor within the Proposal shall apply under this Agreement as if fully rewritten herein. The Contractor further certifies the following: NEW EMPLOYEE WORK ELIGIBILITY STATUS The Contractor is required and hereby agrees to use a federal immigration verification system to determine the work eligibility status of new employees physically performing services within the State of Nebraska. A federal immigration verification system means the electronic verification of the work authorization program authorized by the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, 8 U.S.C. 1324a, known as the E -Verify Program, or an equivalent federal program designated by the United States Department of Homeland Security or other federal agency authorized to verify the work eligibility status of a newly hired employee. If the Contractor is an individual or sole proprietorship, the following applies: 1. The Contractor must complete the United States Citizenship Attestation Form, available on the Department of Administrative Services website at www.das.state.ne.us. 2. If the Contractor indicates on such attestation form that he or she is a qualified alien, the Contractor agrees to provide the US Citizenship and Immigration Services documentation required to verify the Contractor's lawful presence in the United States using the Systematic Alien Verification for Entitlements (SAVE) Program. 3. The Contractor understands and agrees that lawful presence in the United States is required and the Contractor may be disqualified or the contract terminated if such lawful presence cannot be verified as required by Neb. Rev. Stat. §4-108. This agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this agreement shall not be binding upon either party except to the extent incorporated into this contract and the contract documents. The rights of each party under this Agreement may not be assigned or transferred to any other person, firm or corporation or other entity without the prior written consent of the other party. Olsson C-2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 The Contractor specifically agrees not to discriminate against any recipients of services on the basis of race, color, sex, religion, creed, age, marital status, physical or mental disability, political affiliation, national origin or ancestry, and not to discriminate against any employees or applicant for employment on the basis of race, color, sex, religion, creed, age, marital status, physical or mental disability, political affiliation, national origin or ancestry. IN WITNESS WHEREOF, the parties hereto have set their hands for the purpose herein expressed, this 16 6 day of to 43 . Owner: Blair Airport Authority 218 South 16th Street Blair, NE 68008 By: (Of a Olsson Contractor: Midwest DCM 8719 S. 135th Street, Ste. 100 Omaha, NE 68138 By: (Office or Position o igner) r C-3 PERFORMANCE BOND No.146208 3 4 KNOW ALL MEN BY THESE PRESENTS: 5 6 That we Midwest DCM, Inc. as Principal, 7 hereinafter referred to as "Contractor", and Inland Insurance Company as Surety, are 8 held and firmly bound, unto the Blair Airport Authority of Blair, Nebraska in the penal sum of 9 Two Hundred Thirty Thousand Three Hundred Seventy-two and o0/100 ----------------------------- ($230,372.00) dollars 10 and for the payment of which we do hereby bind ourselves, our heirs, executors, administrators, 11 successors and assigns, jointly, severally, and firmly by these presents. 12 13 The Contractor has been awarded by the Blair Airport Authority of Blair, Nebraska the 14 contract for items numbered Base Bid: 1-6, copy of said contract together with all of its terms, 15 covenants, conditions and stipulations is incorporated herein and made a part hereof as fully 16 and amply as if said contract were recited at length herein. 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 NOW THEREFORE, if the Contractor shall in all respects fulfill this said contract according to the terms and the tenor thereof, and shall faithfully discharge the duties and obligations therein assumed, then the above obligation is to be void and of no effect; otherwise to be and remain in full force and virtue in law. It is expressly understood and agreed that this bond is given to secure and does secure not only the faithful performance by the principal herein named of said contract for the construction work as specified in said contract and in strict accordance with the terms of said contract and the plans, specifications and all special provisions made a part thereof; and shall also well and truly perform and fulfill all the undertakings, covenants, terms, conditions, and agreements of any and all duly authorized modifications of said contract that may hereafter be made, notice of which modification to the surety being hereby waived SIGNED this day of IY) (44.q 4od Midwest DCM, Inc. Principal Surety By. Inland Insurance Company Signatu 11 Surety I te & es 14 &> -r— Title Title Jacqueline L. Drey Attorney in Fact S nature Olsson PB -1 4 5 6 7 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 PAYMENT BOND No.146208 KNOW ALL MEN BY THESE PRESENTS: That we Midwest DCM, Inc. as Principal, hereinafter referred to as "Contractor", and Inland Insurance Company as Surety, are held and firmly bound, unto the Blair Airport Authority of Blair, Nebraska in the penal sum of Two Hundred Thirty Thousand Three Hundred Seventy-two and 00/100 ----------------------------- ($230,372.00) dollars and for the payment of which we do hereby bind ourselves, our heirs, executors, administrators, successors and assigns, jointly, severally, and firmly by these presents. The Contractor has been awarded by the Blair Airport Authority of Blair, Nebraska the contract for items numbered Base Bid: 1-6, copy of said contract together with all of its terms, covenants, conditions and stipulations is incorporated herein and made a part hereof as fully and amply as if said contract were recited at length herein. NOW THEREFORE, if the Contractor shall pay for all material, supplies, tools, fuel, lubricants, equipment, equipment rental machinery, insurance premiums and services used or consumed in the construction of the work by the Contractor or any subcontractors, and the Contractor shall pay to the Unemployment Compensation Fund of the State of Nebraska and the State Unemployment Insurance Trust Fund the unemployment contributions and interest due under provisions of the Nebraska Employment Security Law on wages paid to individuals employed in the performance of this contract, and shall pay for all other just claims filed against him or any subcontractors in carrying out the provisions of said contract, and if such payment be made then this obligation shall be null and void; otherwise it shall remain in full force and effect. SIGNED this _ day of MCI L-_. Midwest DCM, Inc. Principal Surety By _ Inland Insurance Company Signature Surety PA,0 10 ksWr Jacqueline L. Drey Title Attorney in Fact 1 MfulmAN�tl !�• ..�t, . - Olsson PB -2 INLAND INSURANCE COMPANY Lincoln, Nebraska POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That the INLAND INSURANCE COMPANY, a corporation of the State of Nebraska having its principal office in the City of Lincoln, Nebraska, pursuant to the following Bylaw, which was adopted by the Board of Directors of the said Company on July 23, 1981, to wit: "Article V -Section 6. RESIDENT OFFICERS AND ATTORNEYS -IN -FACT. The President or any Vice President, acting with any Secretary or Assistant Secretary, shall have the authority to appoint Resident Vice Presidents and Attorneys -In -Fact, with the power and authority to sign, execute, acknowledge and deliver on its behalf, as Surety: Any and all undertakings of suretyship and to affix thereto the corporate seal of the corporation. The President or any Vice President, acting with any Secretary or Assistant Secretary, shall also have the authority to remove and revolve the authority of any such appointee at any time." does hereby make, constitute and appoint Sharon K. Murray, Firth, Nebraska or David A. Dominiani, Lincoln, Nebraska or Maura P. Kelly, Council Bluffs, Iowa or Joan Leu, Ralston, Nebraska or Jacqueline L. Drey or Kevin J. Stenger or David G. Jesse, Omaha, Nebraska or Dustin Cooper, Elkhorn, Nebraska its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver for and on its behalf, as Surety: Any and all undertakings of suretyship And the execution of such bonds or undertakings in pursuance of these presents, shall be as binding upon said Company, as fully and amply, to all intents and purposes, as if they had been duly executed and acknowledged by the regularly elected officers of the Company at its offices in Lincoln, Nebraska, in their own persons. The following Resolution was adopted at the Regular Meeting of the Board of Directors of the INLAND INSURANCE COMPANY, held on July 23,1981: "RESOLVED, That the signatures of officers of the Company and the seal of the Company may be affixed by facsimile to any Power of Attorney executed in accordance with Article V -Section 6 of the Company Bylaws: and that any such Power of Attorney bearing such facsimile signatures, including the facsimile signature of a certifying Assistant Secretary and facsimile seal shall be valid and binding upon the Company with respect to any bond, undertaking or contract of suretyship to which it is attached." All authority hereby conferred shall remain in full force and effect until terminated by the Company. IN WITNESS WHEREOF, INLAND INSURANCE COMPANY has caused these presents to be signed by its President and its corporate seal to be hereunto affixed this 16th day of February 20 22 . � t UVj_ Secretary/Treasurer By State of Nebraska ss. County of Lancaster INLANDINSURA On this 16th day of February , 20 22 before me personally came Curtis L. Hartter, to me known, who being by me duly sworn, did depose and say that (s)he resides in the County of Lancaster, State of Nebraska; that (s)he is the President of the INLAND INSURANCE COMPANY, the corporation described in and which executed the above instrument; that (s)he knows the seal of the said corporation; that the seal affixed to the said instrument is such corporate seal; that it was so affixed by order of the Board of Directors of said corporation; that (s)he signed (his) (her) name by like order; and that Bylaw, Article V -Section 6, adopted by the Board of Directors of said Company, referred to in the preceding instrument, is now in force. My Commission Expires February 16, 2026. W' Q/Gv Notary Public W ERAL NOTARY -state of Nebraska TARA MARTIN My Comm. Exp. February 16, 2026 1, Philip C. Abel, Director of INLAND INSURANCE COMPANY, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney executed by said INLAND INSURANCE COMPANY, whi h. is sjill in full force and effect. y Signed and sealed at the City of Lincoln, Nebraska this � day of 2�J--• Oil" A CORPORATE 0 s SEAL Director s.. .1 A� 0® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDYYY) /Y 4/13/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER AssuredPartners Great Plains LLC 4200 University Ave., Suite 200 West Des Moines IA 50266-5945 CONTACT NAME: Dana Firkins PHONE FAX c No E • 515-237-0167 A/c No): 515-237-0167 ADDRESS: dana.firkins@assuredpartners.com INSURERS AFFORDING COVERAGE NAIC # Y INSURERA: SFM Mutual Insurance Company 11347 6X00947 INSURED MIDWPAV-01 Midwest DCM, Inc. 8719 S 135th St Ste 100 INSURER B : EMCASCO Insurance Company 21407 INSURER C: Employers Mutual Casualty Company 21415 INSURER D: Omaha NE 68138 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1773019404 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDD�YY MMID mYY LIMITS B X COMMERCIAL GENERAL LIABILITY Y Y 6X00947 3/11/2023 3/11/2024 EACH OCCURRENCE $1,000,000 _7O CLAIMS -MADE � OCCUR A IG PREM SESEa occurrence $ 500,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 POLICY [X] PRO [�] LOC JECT PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: C AUTOMOBILE LIABILITY Y 6X00947 3/11/2023 3/11/2024 COMBINED SINGLE LIMIT $1,000,000 Es accident BODILY INJURY (Per person) $ AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accldenl HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY $ xiANY Drive Ot Car C X UMBRELLALIAB X OCCUR Y Y 6X00947 3/11/2023 3/11/2024 EACH OCCURRENCE $3,000,000 AGGREGATE $ 3,000,000 EXCESS LIAB CLAIMS -MADE DED I X RETENTION $ n $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N Y 83304.207 3/11/2023 3/11/2024 X STATUTE EERH ANYPROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBEREXCLUC N N I A EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Blair Executive Airport, NDOT Project No. BTA SA -09 The Blair Airport Authority and Olsson, Inc. are Additional Insured - Owners, Lessees or Contractors including completed operations on a primary and non contributory basis when required in a written contract or agreement with respects to the General Liability policy per form CG7174.3 (10/13) General Liability Aggregate applies separately to each project per form CG7429 (11/98) Fellow Employee coverage applies to the General Liability policy per form CG7578 (02/19) See Attached,,. CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Blair Airport Authority 218 South 16 Street AUTHORIZED REPRESENTATIVE . �P_ Blair NE 68008 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: MIDWPAV-01 LOC #: A� ® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY AssuredPartners Great Plains LLC NAMED INSURED Midwest DCM, Inc. 8719 S 135th St Ste 100 Omaha NE 68138 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE low Employee coverage applies to the Auto Liability policy per form CA7450 (11/17) iver of Subrogation applies when required in a written contract or agreement to the General Liability policy per form CG7578 (02/19) iver of Subrogation applies when required in a written contract, agreement or permit to the Auto Liability policy per form CA7450 (02/22) of subrogation applies to the Workers Compensation policy per form WC000313 (04/84) Notice of Cancellation provided by us - Designated Entity - 30 Days per form IL7338 (05/15) lation Notice - 30 days with respects to the Workers Compensation policy per form WC990301 (11/09) Umbrella policy is follow form over the General Liability, Auto Liability and Workers Compensation policy subject to policy exclusions per form C00001 (04/13) Waiver of subrogation in favor of certificate holder applies when required in a written contract or agreement with respects to the Umbrella policy per form CU7460 (12/15) ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BLAIR, NEBRASKA BLAIR EXECUTIVE AIRPORT NDOT PROJECT NO. BTA SA -09 PROPOSALFORM ALL =PAGES '(1-4) OF THIS FORM MUST BE SUBMITTED WHEN BIDDING TO: Blair Airport Authority THE BID OF W61,0FST Name of Contractor The undersigned hereby proposes to furnish all labor, permits, materials, machinery, tools, supplies, equipment and appurtenances necessary to faithfully perform all work required for construction of the Project in accordance with the bid documents, specifications, project drawings, and issued addenda within the specified time of performance for the following prices. Item Unit Total No. Sec Description Quantity Unit Price Amount BASE BID 1 Ols son Mobilization 1 LS $ $ 2 Olsson- Manhole Adjustment and 1 LS $ $ 101 Appurtenances 3 NDOT- Construction Staking and 1 LS $$ q NO quo 114 Surveying 4 NDOT- Excavation (Established 470 CY $ $ 2,115-0 205 Quantity) 5 NDOT 6" Crushed Rock Base 1,201 SY $ $ 6 NDOT- 8" Concrete Pavement, 476- 1,150 SY $ $ 603 4,000 BASE BID SUBTOTAL $ ALTERNATE BID NO.1 7 Ols son Mobilization 1 LS $ $ 8 Olsson- Remove Manhole and 1 LS $ $ 101 Appurtenances 9 01101 sson 8" PVC Pipe Removal 65 LF $ $ 10 Olsson -101 Drop Manhole and Casting 1 LS $00wo$ b000 11 Olsson- 8" PVC SDR 26 Pipe and 65 LF $ $ 101 Insulation ALTERNATE BID NO. 1 SUBTOTAL $ BASE BID + ALTERNATE BID NO. 1 TOTAL $ Olsson P-1 ACKNOWLEDGEMENTS BY BIDDER a. By submittal of a proposal, the BIDDER acknowledges and accepts that the quantities established by the OWNER are an approximate estimate of the quantities required to fully complete the Project and that the estimated quantities are principally intended to serve as a basis for evaluation of bids. The BIDDER further acknowledges and accepts that payment under this contract will be made only for actual quantities and that quantities will vary in accordance with the General Provisions subsection entitled "Alteration of Work and Quantities". b. The BIDDER acknowledges and accepts that the Bid Documents are comprised of the documents identified within the Instructions to Bidders. The BIDDER further acknowledges that each of the individual documents that comprise the Bid Documents are complementary to one another and together establishes the complete terms, conditions and obligations of the successful BIDDER. C. As evidence of good faith in submitting this proposal, the undersigned encloses a bid guaranty in the form of a certified check or bid bond in the amount of 5% of the bid price. The BIDDER acknowledges and accepts that refusal or failure to accept award and execute a contract within the terms and conditions established herein will result in forfeiture of the bid guaranty to the owner as a liquidated damage. d. The BIDDER acknowledges and accepts the OWNER'S right to reject any or all bids and to waive any minor informality in any Bid or solicitation procedure. e. The BIDDER acknowledges and accepts the OWNER'S right to hold all Proposals for purposes of review and evaluation and not issue a notice -of -award for a period not to exceed 90 days from the stated date for receipt of bids. The undersigned agrees that upon written notice of award of contract, he or she will execute the contract within fifteen (15) dans of the notice -of -award and furthermore and provide executed payment and performance bonds within fifteen 15 days from the date of contract execution. The undersigned accepts that failure to execute the contract and provide the required bonds within the stated timeframe shall result in forfeiture of the bid guaranty to the owner as a liquidated damage. g. Time of Performance: By submittal of this proposal, the undersigned acknowledges and agrees to commence work within ten (10) calendar days of the date specified in the written "Notice -to -Proceed" as issued by the OWNER. The undersigned further agrees to complete the Project within the following Working Days: Base Bid: 20 Working days Alternate Bid No. 1: 5 Working Days Max Total Project: 25 Working Days h. from the commencement date specified in the Notice -to -Proceed The working day count will be cumulative to the Base Bid plus Alternate Bid No. 1 that are awarded. The time allowance for the overall project is 25 working days. The undersigned acknowledges and accepts that for each and every working day the project remains incomplete beyond the contract time of performance, the Contractor shall pay the non - penal amount of $2,000.00 per working day as a liquidated damage to the OWNER. Olsson P-2 REPRESENTATIONS BY BIDDER By submittal of a proposal (bid), the BIDDER represents the following: a. The BIDDER has read and thoroughly examined the bid documents including all authorized addenda. b. The BIDDER has a complete understanding of the terms and conditions required for the satisfactory performance of project work. C. The BIDDER has fully informed themselves of the project site, the project site conditions and the surrounding area. d. The BIDDER has familiarized themselves of the requirements of working on an operating airport and understands the conditions that may in any manner affect cost, progress or performance of the work e. The BIDDER has correlated their observations with that of the project documents. The BIDDER has found no errors, conflicts, ambiguities or omissions in the project documents, except as previously submitted in writing to the owner that would affect cost, progress or performance of the work. g. The BIDDER is familiar with all applicable Federal, State and local laws, rules and regulations pertaining to execution of the contract and the project work. The BIDDER has complied with all requirements of these instructions and the associated project documents. CERTIFICATIONS BY BIDDER a. The undersigned hereby declares and certifies that the only parties interested in this proposal are named herein and that this proposal is made without collusion with any other person, firm or corporation. The undersigned further certifies that no member, officer or agent of OWNER'S has direct or indirect financial interest in this proposal. The undersigned specifically agrees not to discriminate against any recipients of services on the basis of race, color, sex, religion, creed, age, marital status, physical or mental disability, political affiliation, national origin or ancestry, and not to discriminate against any employees or applicant for employment on the basis of race, color, sex, religion, creed, age, marital status, physical or mental disability, political affiliation, national origin or ancestry. C. The undersigned agrees to comply with all current and applicable federal, state and local rules and regulations governing the safety of men and materials during its operations including observing the requirements of the Occupational Safety and Health Administration (OSHA). d. The undersigned states that they are complying with and will continue to comply with fair labor standards, as defined in Neb. Rev. Stat. § 73-104, (reissue 2016), in the pursuit of their business and in the execution of the contract pursuant to this bid. e. If there is an additional charge for the insurance naming the Blair Airport Authority and the Engineer as an additional insured, the amount must be shown here. The amount shown will not change the total bid. A blank or inserting a zero will mean the Bidder's insurance company does not charge an extra fee for naming the Blair Airport A thority and the Engineer as an additional insured per the Special Provisions. $ Olsson P-3 ATTACHMENTS TO THIS BID and ADDITIONAL SUBMITTALS The following documents are attached to and made a part of this Bid: 1. Bid Guaranty in the form of M The undersigned acknowledges receipt of the following addenda: Addendum Number dated Addendum Number —dated Business: Mit tT- By: (Signature of Authori ed Offi r) RSS e (Printed Name) Address: a E ST a StdCO Title: toP&G–SIAEPJr Olsson P-4 AIA Document A310rM -1970 KNOW ALL MEN BY THESE PRESENTS, that we Midwest DCM, Inc. (Here insert fill name and address or legal title of Contractor) as Principal, hereinafter called the Principal, and Inland Insurance Company (Here insert full name and address or legal title of Surety) a corporation duly organized under the laws of the State of Nebraska as Surety, hereinafter called the Surety, are held and firmly bound unto Blair Airport Authority (Here insertMl name and address or legal title of Owner) as Obligee, hereinafter called the Obligee, in the sum of FIVE PERCENT OF AMOUNT BID Dollars ($ 5% ), for the payment of which sum well and truly to be made, the said Principal and the said Surety, bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, the Principal has submitted a bid for NDOT Project No. BTA SA -09 (Here insert full name, address and description of project) NOW, THEREFORE, if the Obligee shall accept the bid of the Principal and the Principal shall enter into a Contract with the Obligee in accordance with the terms of such bid, and give such bond or bonds as may be specified in the bidding or Contract Documents with good and sufficient surety for the faithful performance of such Contract and for the prompt payment of labor and material furnished in the prosecution thereof, or in the event of the failure of the Principal to enter such Contract and give such bond or bonds, if the Principal shall pay to the Obligec the difference not to exceed the penalty hereof between the amount specified in said bid and such larger amount for which the Obligee may in good faith contract with another party to perform the Work covered by said bid, then this obligation shall be null and void, otherwise to remain in full force and effect. Signed d sealed its 16th day of March, 2023 Midwest DCM Inc. - (Principal) (Seal) ( fitness t c pa-csi jai _ (Title) I r Inland Insurance Company ,p4(,Se (Witness) PnL Jacqueli U. urty (Seal) Attorney -in -Fact AIA Document A310TM —1970. Copyright© 1963 and 1970 by The American Institute of Architects. INLAND INSURANCE COMPANY Lincoln, Nebraska POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That the INLAND INSURANCE COMPANY, a corporation of the State of Nebraska having its principal office in the City of Lincoln, Nebraska, pursuant to the following Bylaw, which was adopted by the Board of Directors of the said Company on July 23, 1981, to wit: "Article V -Section 6. RESIDENT OFFICERS AND ATTORNEYS -IN -FACT, The President or any Vice President, acting with any Secretary or Assistant Secretary, shall have the authority to appoint Resident Vice Presidents and Attorneys -In -Fact, with the power and authority to sign, execute, acknowledge and deliver on its behalf, as Surety: Any and all undertakings of suretyship and to affix thereto the corporate seal of the corporation. The President or any Vice President, acting with any Secretary or Assistant Secretary, shall also have the authority to remove and revolve the authority of any such appointee at anytime." does hereby make, constitute and appoint Sharon K. Murray, Firth, Nebraska or David A. Dominiani, Lincoln, Nebraska or Maura P. Kelly, Council Bluffs, Iowa or Joan Leu, Ralston, Nebraska or Jacqueline L. Drey or Kevin J. Stenger or David G. Jesse, Omaha, Nebraska or Dustin Cooper, Elkhorn, Nebraska its true and lawful Attorneys) -in -Fact, to make, execute, seal and deliver for and on its behalf, as Surety: Any and all undertakings of suretyship And the execution of such bonds or undertakings in pursuance of these presents, shall be as binding upon said Company, as fully and amply, to all intents and purposes, as if they had been duly executed and acknowledged by the regularly elected officers of the Company at its offices in Lincoln, Nebraska, in their own persons. The following Resolution was adopted at the Regular Meeting of the Board of Directors of the INLAND INSURANCE COMPANY, held on July 23,1981: "RESOLVED, That the signatures of officers of the Company and the seal of the Company may be affixed by facsimile to any Power of Attorney executed in accordance with Article V -Section 6 of the Company Bylaws: and that any such Power of Attorney bearing such facsimile signatures, including the facsimile signature of a certifying Assistant Secretary and facsimile seal shall be valid and binding upon the Company with respect to any bond, undertaking or contract of suretyship to which it is attached." All authority hereby conferred shall remain in full force and effect until terminated by the Company. IN WITNESS WHEREOF, INLAND INSURANCE COMPANY has caused these presents to be signed by its President and its corporate seal to be hereunto affixed this 16th day of February 20 22 . tuvi- Secretary/Treasurer By State of Nebraska ss. County of Lancaster INLAND INSURANCE COMPANY C Gtr //4A.—Pres CORPORATE SEAL On this 16th day of February , 20 22 . before me personally came Curtis L. Hartter, to me known, who being by me duly sworn, did depose and say that (s)he resides in the County of Lancaster, State of Nebraska; that (s)he is the President of the INLAND INSURANCE COMPANY, the corporation described in and which executed the above instrument; that (s)he knows the seal of the said corporation; that the seal affixed to the said instrument is such corporate seal; that it was so affixed by order of the Board of Directors of said corporation; that (s)he signed (his) (her) name by like order; and that Bylaw, Article V -Section 6, adopted by the Board of Directors of said Company, referred to in the preceding instrument, is now in force. nn J GENERAL NOTAR=MAFTTIN W',AJ TAR My Comm. E My Commission Expires February 16, 2026. Notary Public 1, Philip C. Abel, Director of INLAND INSURANCE COMPANY, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney executed by said INLAND INSURANCE COMPANY, which is still in full force and effect. Signed and sealed at the City of Lincoln, Nebraska this 16th day of March . 20 23 Director