Subcontractor services letter for DEP, February 2012

NYC 9/11 Public Portal Document

~ ~; =" ' CITY OF:NEW YORK SUBCONTRACTOR APP.ROVALtFORM ac. 'F~`~" ' ,PR_IMEeCONTRACTINFORMATION "" ~ ' {* r '„ ' ~" Agency: DEP Unit/Div: BEDC FMS Contract No.: 82620060020284 PIN:-.~. Contract Value: $7,372,760 Registration Date: 01/10/2006 ~r Contract Number / Description: EE-GEO-02 & EE-GEO-03 Geotechnical Engineering Services for Water Tunnel Construction Contract Subject to a Project Labor Agreement (PLA) ❑

Name: Jenny/BAC Killam, A Joint Venture Phone: 973-379-6699 Fax: 913-379-6774 Address: 475 Park Avenue South, 10`" Floor City: New York State/Zip: NY 10016 --------------------------- EIN/SSN: L-~.._ P!!. .._. E-Mail: [email protected] ~,' ~Y ~ C + Z 'f ►£- SUBCONTRACTOR Co. Name: Galyn Rippentrop Co. ,Representative (Please Print): Phone: (812) 431-8364 Fax: (605) 339-0986 Address: P.O. Box 89321 City: Sioux Falls I State/Zip: SD / 57109 'z k EIN/SSN: PII E-Mail: Ri 3M © mail.com Subcontract Description: Plumbing ❑ HVAC ❑ Electrical ❑ or Other ® (describe below) a0 Reviewing information, travel to Technical Review Committee (TRC) meeting(s), participation in the TRC, and providing input to report prepared by others Agreed-Upon Subcontract Value: $15,000 Approx Start Date: 02/01/2012 Approx End Date: 05/31/2012

O« z Subcontractor Signed Letter of Assent El (if Prime Contract is subject to a Project Labor Agreement) 1 C1 f,w Subcontractor is DSBS-certified as: M/WBE ❑ EBE ❑ or LBE ❑ (check all that apply & note status below) YES ❑ Application Pending ❑ Intends to Apply ❑ NO ❑ Subcontractor Prevailing Wage or Living Wage Statement (if applicable) ❑ Subcontractor's Experience Modification Rating (EMR): (Letter from insurance carrier to verify rating F must be included). Prime Contractor Certification: I her firm that the information supplied is true and correct.

Signature of Prime Contractor Title Project Manager Print Name Thomas P. Kwiatkowski Date i a...

. 'AGENCYjRRELIMINARY REVIEW PLEASEKSEE'PAGE-'2,,F,OR'•INSTRUCTION3 Agency Preliminary Review Completed By: Date w

fi 1.VENDEX`❑ 2 Employment ❑ 3. References 0 4. PLAIT-, 5. Apprenticeship ❑ 6. Licenses ❑

.+ p,;",5Na'., P,RIMECONTRACTOR RESPONSE i =* p For each of the boxes checked in the agency preliminary response above, I have informed the Subcontractor of all ;Z relevant requirements and provided all requested documentation. Initials: Date

3 ~ ?P 'AGENCY?FINAL'RESPONSE ,' au= ~ . k Final Agency Approval: Granted❑ Denied❑

Signature: Date

It Subcontracted Amount Has Changed, Please Enter;The;Revised.Amount: And;Resubmit:,L: ;,

MOCS Subcontractor Approval Form (Sept. 2010)

NYC-WTC 000159324