CONTRACTOR ACKNOWLEDGMENT OF COMPLIANCE WITH CALIFORNIA EQUAL PAY ACT SECTION A:
To be completed by City Representative Prior to Distribution to Contractor:
City Representative Phone Project Spec No.
Department Contract/Proposal Name __
SECTION B:
This is an Original Revised form (check one). If Original, complete all that applies. If revised, complete Contractor Name and include any changed data.
Contractor/Consultant Name____________________ Phone
Street Address City State Zip
Type of Submission (Check One) Bid Proposal Qualification Contract/Agreement/Amendment SECTION C:
The undersigned Contractor’s Representative acknowledges by his or her signature the following:
It is the policy of the City of Hercules to avoid awarding contracts for supplies, construction, maintenance, professional or other services to contractors who are not in compliance with the equal pay requirements of the California Equal Pay Act.. The awarding of a contract or the approval of payments or expenses under a contract by a City Official, to a person or contractor not in compliance with the California Equal Pay Act, is regarded as a violation of this Section.
I have read Hercules Ordinance Number 534 and certify that I/we have not in the past 5 years been found to be in violation of the California Equal pay Act, and I/we have not knowingly, nor will I/we in the future, enter into a contract with the City of Hercules or accept payment from the City of Hercules when to do so is in violation of Ordinance Number 534 .
If circumstances require changing the information on this form while I/we have a bid, proposal, or qualifications under review, or while we are under contract with the City, we will amend this form within five business days.
Signature Date
Print Name of Signer Position
SECTION D:
To Be Completed by Administrative Services Department with the City of Hercules after Submission of the Compl eted Form by Contractor
Date Received by City By XXXXXXXX
via DocuSign
XXXXXXXXX
via DocuSign
DocuSign Envelope ID: F2D43688-4A0E-44B0-AFEF-DA78CA58C3E4 925-932-1710
X
CA 94598
Vice President
2795 Mitchell Drive
9/5/2022
Carollo Engineers
Anne E Prudhel
Walnut Creek