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Project Name: Mechanical Engineering Consultant for Upgrades at Hill Canyon Treatment Plant and Los Robles Golf Course CI 5647 & CI 5662
FIRST AMENDMENT TO
AGREEMENT FOR PROFESSIONAL SERVICES
BETWEEN THE CITY OF THOUSAND OAKS
AND
GLUMAC
Contract No. 14083-2025
THIS FIRST AMENDMENT to the Agreement for Professional Services entered into between the CITY OF THOUSAND OAKS, a municipal corporation, (hereafter “City”) and (“Consultant”), entitled Mechanical Engineering Consultant for Upgrades at Hill Canyon Treatment Plant and Los Robles Golf Course CI 5647 & CI 5662 and dated September 4, 2025, (herein “Contract”) is made this 25th day of August, 2026.
RECITALS
A. City and Consultant entered into the Agreement on September 4, 2025, for Mechanical Engineering Consultant for Upgrades at Hill Canyon Treatment Plant and Los Robles Golf Course CI 5647 & CI 5662.
B. Section 3 of Contract allows for City to authorize extra services to be performed by Consultant. City and Consultant desire to amend the Contract to expand the Scope of Work to include construction administration services for the Mechanical System Upgrades Project at Hill Canyon Treatment Plant (CI 5647).
C. Section 3 of Contract currently provides for a not -to-exceed amount of $75,000 for services generally and briefly described as mechanical engineering consulting services. City is in need of increasing the not -to-exceed amount by $35,000 for a new not -to- exceed total of $110,000 to compensate Consultant for requested additional services.
D. Section 5 of the Contract provides for a termination date of March 31, 2027. City and Consultant desire to extend the date of the contract.
E. City and Consultant desire to expand the scope of services, increase the not-to-exceed amount, and extend the date of the Contract while keeping all other terms intact.
ATTACHMENT #2
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AGREEMENT TO AMEND
NOW, THEREFORE, the undersigned parties to Contract agree to amend Contract as described below:
Part 1 . Section 2 of Contract is hereby amended to include construction administration services at the HCTP site and Exhibit “A” is hereby replaced with Exhibit “A-1” attached hereto and incorporated herein, and Section 2 will now read in its entirety as follows:
2. DESCRIPTION OF SERVICES
Professional Services in conjunction with engineering consultant services at the City owned Hill Canyon Treatment Plant (HCTP) and Los Robles Golf Course (LRGC).
Services and deliverables shall generally include engineerin g and construction administration services for upgrade and/or equipment replacement of the mechanical systems and are more particularly set forth in the Scope of Work, attached as Exhibit “A- 1”, which is incorporated herein by reference.
Part 2 . The sum of $35,000 is hereby added to the Contract to compensate Consultant for additional services set forth in the amended Scope of Work. Exhibit “B” is hereby replaced in it s entirety with Exhibit “B-1,” attached hereto and incorporated herein. Accordingly, Subsection 3 (a) of Contract is hereby amended to read in its entirety as follows:
3. COMPENSATION AND PAYMENT
(a) Maximum. The total compensation payable to Consultant by City for the services under this Agreement SHALL NOT EXCEED the sum of $110,000 (herein “not -to-exceed amount ), and shall be earned as the work progresses on the following basis:
Billed monthly as a percentage of completion based on lump sum amounts per the Consultant’s Schedule of Fees, attached as Exhibit “B -1” and incorporated herein, except for Construction Administration Services which will be invoiced monthly, at the hourly rates and with reimbursement to Consultant set forth in Consultant’s Schedule of Fees. The rates and expenses set forth in those exhibits shall be binding upon Consultant until March 31, 2027, after which any change in the rates and expenses must be approved in writing by the City’s Project Manager (City to be given 60 days’ notice of any rate increase request), provided the not to exceed amount is the total compensation due to Consultant for all work described under this Agreement.
Part 3. Section 5 of the Contract authorizes the Contract term to be extended. The term of the Contract is hereby extended, and Section 5 of the Contract is amended to FIN:201-10\jr\H:\COMMON\Council\2026\Facilities\08252026CCMtg\CI 5647 & CI 5662 Glumac Consulting Services 13365- 2023A1.docx
reflect a new termination date of August 31, 2027.
Part 4. All terms used in Part 1, 2 and 3 above shall have the meanings ascribed thereto in Contract. Except as amended in Part 1, 2 and 3 above, all other sections, terms, obligations, duties, clauses, and provisions of Contract shall remain the same.
IN WITNESS WHEREOF, the parties execute this First Amendment to Contract as of the date set forth above.
GLUMAC
Berian Berg
Discipline Lead – Mechanical, VP
Nick Gallucci
Strategic & Innovative Pursuits, VP
CITY OF THOUSAND OAKS
Mikey Taylor, Mayor
ATTEST:
Laura B. Maguire, City Clerk
APPROVED AS TO ADMINISTRATION:
Andrew P. Powers, City Manager
APPROVED BY DEPARTMENT HEAD:
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Jaime Boscarino, Finance Director
APPROVED AS TO FORM:
Office of the City Attorney
Tracy Friedl, Assistant City Attorney
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EXHIBIT A-1
GLUMAC
Mechanical Engineering Consultant for Upgrades at Hill Canyon Treatment Plant and Los Robles Golf Course CI 5647 & CI 5662
SCOPE OF WORK
PROJECT SCOPE
General Program: The project includes central plant replacement and a control system replacement at Los Robles Golf Course (LRGC) and equipment and a control system replacement at Hill Canyon Treatment Plant(HCTP). Consultant's services shall include the following tasks for each site as listed:
MECHANICAL/ELECTRICAL/PLUMBING (MEP) ENGINEERING SERVICES TO BE
PERFORMED FOR EACH SITE
Consultant shall perform the following tasks and provide the listed deliverables:
1) ***Evaluation and Documentation of Existing System
a) Facilitate a kick-off meeting to initiate the project and tour the facilities to collect initial data for both project locations.
b) Complete a field investigation to verify accuracy of available record drawings and complete a visual observation of the existing chillers, boilers, and related central plant equipment. This will include identification of all equipment and/or systems to be replaced, upgraded, or otherwise altered. Consultant shall prepare a report outlining the findings of the field observation and the perceived accuracy of available record drawings. This report will also identify areas that were inaccessible or were overly congested and not easily observed above the ceiling prior to commencement of services included in this contract. c) Document all existing mechanical systems and components and provide as-built documentation to be used in the proposed design for both project locations. 2) ***Ventilation Assessment
Create a schedule for all existing AHUs, fan coil units (FCU), and fans. Complete calculations to determine code required or design ventilation and exhaust airflow for each unit and include in each schedule. Create schedule for supply and return airflow based on as-built design drawings provided by the City. All schedules will note to replace automatic control valves (as applicable) and to test and balance existing equipment to design airflow, including ventilation rates.
3) ***Construction Documents - MEP
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a) Prepare MEP construction documents and specifications and a construction/bid- ready set of documents. The construction document packages will include the following:
i) MEP Specifications in CSI format.
ii) HVAC drawings including schedules, details, floor plans, riser diagrams, and sections through mechanical rooms and complex spaces. iii) Electrical drawings including schedules, details, floor plans, and riser diagrams. b) Provide services required to produce documentation necessary to qualify a project under the Title 24 energy code.
4) ***Bid Support - MEP
a) Schedule a Project Manager to attend an in-person pre-bid walk-through on-site. b) Review and respond to MEP and structural related RFIs (Request for Information) pertaining to the design.
c) Assist the City with the issuance and review of a bid package. Consultant will issue a bid set of drawings. City will develop general construction specification sections (CSI Division 1),and will compile the overall bid package and complete the bid process.
d) Provide technical and commercial analysis of low bid submission.
GENERAL CONDITIONS
1) The project includes a single bid package for each site, two (2) total. 2) STRUCTURAL ENGINEERING CONSULTANT SERVICES: Structural design of the services included in this proposal assume the following:
a) If the information on the existing slab-on-grade inside the existing chiller yard is deemed by the structural engineer to be inadequate, the existing slab on grade will be partially demolished and retrofitted to adequately anchor and support the new chiller unit.
b) The existing foundation is adequate to support the new boilers and associated equipment. If the foundation is found to be inadequate or insufficient as -built information is available, the partial demolishing and replacement of the existing foundation will be required.
c) The design of foundation and anchorage will be performed utilizing the 2019 California Building Code, ACI 318 and ASCE 7-16.
d) Greenbook specifications will be utilized for this project. e) The values for Class 5 materials, found in Table 1806.2 “Presumptive Load - Bearing Values”, will be utilized for the design of all foundations. If inadequate FIN:201-10\jr\H:\COMMON\Council\2026\Facilities\08252026CCMtg\CI 5647 & CI 5662 Glumac Consulting Services 13365- 2023A1.docx
information is provided, a geotechnical investigation may be required to design the sub-slab preparation as an additional service.
3) ELECTRONIC DESIGN DOCUMENTATION: The project will be completed using AutoCAD.
SITE SPECIFIC INCLUSIONS
1) LRGC:
a) ***Design for the replacement of one slab-on-grade, 80-ton air-cooled chiller and its associated pumps, expansion tank, air separator, and pot feeder. b) ***The design for a temporary chiller to serve the building during construction. c) ***Design for the replacement of one 990 MBH indoor gas boiler and its associated pumps, expansion tank, air separator, and pot feeder. d) ***Scheduling of all existing air handling units, fan coil units, and fans to note design airflows of supply, return, ventilation, and exhaust rates. All schedules will note to replace automatic control valves (as applicable) and to test and balance existing equipment to design airflow, including ventilation rates. e) ***Perform a building load analysis to size the new chiller and boiler based on building heat load, including a brief energy savings and efficiency report. i) Provide documentation (as-needed) to meet the requirements of Title-24 using the prescriptive compliance approach.
ii) Provide the following energy consulting services to understand the heating and cooling load profiles at the facility and aide in the sizing of replacement equipment.
Collect available cooling and heating data from existing facilities and central plants.
Meet with facilities staff to understand existing operations, including equipment setpoints and HVAC schedules.
Obtain as-built drawings from the City to understand existing building layout and systems.
Develop annual hourly heating and cooling load profile for the building using energy modeling software.
Model up to three (3) new chiller selections and compare the energy consumption of these against the existing chiller performance.
Provide an energy report outing the findings of the building load and energy analysis study.
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Facilitate one (1) virtual meeting with building facility staff to review the load profiles.
f) ***Design a VRF system to cool the kitchen.
g) ***Provide control sequences, schematics, and detailed specifications for BAS software in the buildings for public bid process. The mechanical control system will be replaced with an Automated Logic control system. h) Perform the following Structural Engineering Services i) ***Foundation Design for Equipment at Los Robles Golf Course. • ***Site visit to verify as- built drawings and assess condition of existing concrete box structure.
• ***Review existing as-builts and Shop Drawings for new equipment. • ***Provide signed and stamped Structural Calculations by a duly licensed Civil or Structural Engineer in the State of California. • ***The replacement/retrofit of one slab-on-grade, 80-ton air-cooled chiller (6,320 pounds) and its associated
pumps (2x250 pounds), expansion tank (estimating
1200#), air separator (220 pound), and pot feeder.
• ***The anchorage design for of one 990 MBH indoor gas boiler (750 pounds) and its associated pumps (2x250
pounds), expansion tank (estimating 800 pounds), air
separator (100 pounds), and pot feeder. Consultant may
assume that the existing foundation is adequate to
support the new equipment. If the foundation is found to be inadequate or insufficient as built is available, the partial demolishing and replacement of the existing
foundation will be required.
• ***Produce Structural Drawings/Details S-04
— S-05: Foundation
Details for New Equipment
• ***Produce Structural Drawings/Details:
• S-01: General Notes
• S-02: Special Inspections/Typical Details
• S-03: Structural Details
ii) Equipment Anchorage Design at Los Robles Golf Course. • ***Provide signed and stamped Structural Calculations by a duly licensed Civil or Structural Engineer in the State of California. • ***The anchorage design for 80- ton air -cooled chiller FIN:201-10\jr\H:\COMMON\Council\2026\Facilities\08252026CCMtg\CI 5647 & CI 5662 Glumac Consulting Services 13365- 2023A1.docx
(6,320 pound) and its associated pumps (2x250
pounds), expansion tank (estimating 1200#), air
separator (220 pound), and pot feeder.
• ***The anchorage design for of one 990 MBH indoor gas boiler (750 pounds) and its associated pumps (2x250
pounds), expansion tank (estimating 800 pounds), air
separator (100 pounds), and pot feeder. Consultant may
assume that the existing foundation is adequate to
support the new equipment. If the foundation is found to be inadequate or insufficient as built is available, the partial demolishing and replacement of the existing
foundation will be required.
• ***Produce Structural Drawings/Details S-06: Anchorage Details • ***Bid Support at Los Robles Golf Course.
• Respond to contractor comments during active bidding
• Construction Administration at Los Robles Golf Course. • Review and provide five (5) maximum comments for
Concrete Mix Design, Anchorage/Steel Submittal,
Grating Submittal, Rebar Submittal as needed.
• Respond to two (2) RFI's.
• Perform/attend two (2) Structural Observation/On-Site Progress Meetings
iii) Construction Administration Phase – MEP.
iv) Schedule a Project Manager and all necessary team members to attend a total of three (1) on-site construction progress meetings. During on-site meeting, Project Manager and team shall:
• Observe the completed subtasks and witness any work-in-progress. • Review installation progress and ensure that the contractor is on schedule.
• Maintain a punch list of incomplete work.
• Provide field reports of the findings during site visits. v) Review, respond, and approve all submittal material and shop drawings for substantial conformity with the intent of the contract plans and specifications. vi) Review and respond to MEP and structural related requests for information and clarification pertaining to Consultant's design. Detailed information and technical guidance shall be provided so that all requests are satisfied. vii) Review close-out documents including but not limited to warranties, manuals, FIN:201-10\jr\H:\COMMON\Council\2026\Facilities\08252026CCMtg\CI 5647 & CI 5662 Glumac Consulting Services 13365- 2023A1.docx
and as-builts.
i) System Commissioning Management – MEP
i) Attend the system and equipment testing and commissioning. ii) Test results will be documented in a punch list with responsibilities for correcting shortcomings assigned to the appropriate parties. j) Construction Close-out will include a complete final on-site walk-through to ensure all of the items on the punch list were addressed. k) The Gardens Controls: add Automated Logic Controls system to connect the mechanical equipment serving The Gardens to the LRGC BAS control system. i) Add mechanical and electrical sheets for The Gardens showing existing HVAC equipment to be tied into the LRGC BAS control system. ii) Produce and provide additional control sequences and schematics for the HVAC equipment serving The Gardens.
iii) Construction administration to verify installation and respond to RFIs and submittals. This includes one (1) punch walk site visit and is assumed to be completed in conjunction with review of other scope items. 2) HCTP:
a) ***Provide control sequences, schematics, and detailed specifications for BAS software in the building for public bid process. The mechanical control system will be replaced with an Automated Logic control system. b) ***Provide design documents showing the HVAC control panels will be replaced at the following buildings:
i) Admin Building
ii) GBT Building
iii) Dewatering Building
iv) Tertiary Filter Building (Filter Pipe Gallery)
v) Maintenance 2
vi) Blower Building 1
vii) Blower Building 2
c) ***Dewatering Building Exhaust System Upgrade and Motor Control Center (MCC) Integration. Consultant may make the following assumptions:
i) At some point since the original construction of the Dewatering building, the heating ventilation unit (HVU) and exhaust fans (EFs) were altered to reduce airflow to the dewatering room. This was completed after the dewatering equipment was replaced with a new piece of equipment requiring less floor area. However, the reduced airflow is incapable of removing the chemical FIN:201-10\jr\H:\COMMON\Council\2026\Facilities\08252026CCMtg\CI 5647 & CI 5662 Glumac Consulting Services 13365- 2023A1.docx
off-gassing of the new equipment and will need to be restored to the original design value.
ii) The existing building structure for the generator/dewatering building is capable of supporting the new exhaust fans and will not require major adjustment to the existing framing members.
iii) The design of foundation and anchorage will be performed utilizing the 2019 California Building Code, ACI 318 and ASCE 7-16.
iv) There are 14 enclosed MCC and switchboard rooms located throughout the HCTP campus that contain PTAC units to counteract the heat produced by the electrical equipment contained within. In the past, these PTAC units have failed and have been unable to cool the space to the desired temperature. In order to monitor these rooms, temperature sensors will be added to all 14 rooms, tied into the new ALC control system, and programed with alarms to notify staff when temperatures exceed 80° F. In addition, the existing exhaust system in these rooms will be retrofitted to reduce electrical power consumption and provide “free cooling“ at night when temperatures fall below the space setpoint.
v) The City will provide data connections from the campus IT network to all MCC and switchboard rooms in order for the new temperature sensors to tie into the new ALC control system.
d) ***Prepare Construction Documents for modifications to replace all eight (8) variable frequency drives (VFDs) in the Operations building at the Hill Canyon Treatment Plant (HCTP). Each VFD serves a different piece of mechanical equipment, including two chilled water pumps, two air handling units, three exhaust fans, and one relief fan.
i) Add new mechanical and electrical sheets showing VFD locations and schedules.
ii) Produce and provide additional specifications sections. iii) Revise the control system change scope to include new wiring for the new VFDs.
e) ***Prepare Construction Documents for modifications to alter the heating ventilation unit (HVU) and replace the exhaust fans (EFs) in the De- watering Building.
i) Add new mechanical and electrical sheets showing HVU, EFs, diffusers, and electrical panel locations and schedules.
ii) Structural engineering required to replace rooftop EFs. iii) Produce and provide additional specifications sections.
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f) ***Prepare Construction Documents for modifications in the MCC and Switchboard Rooms.
i) Add new mechanical sheets showing typical MCC/switchboard room controls and components including the addition of a temperature sensor, OSA actuator, and time clock.
ii) Produce and provide additional specifications sections. g) Update the design documents to remove Maintenance Building 1 from the control system replacement scope, as Maintenance Building 1 has already been converted to the Automated Logic Controls system. Maintenance Building 1 will be shown in the design documents to be connected and integrated into the site- wide BAS control system.
h) Update the design documents to connect Blower Buildings 1 & 2 to the site BAS control system, add two- way BAS communication to the chiller that serves the Administration Building, and add a temperature sensor to the Thickening Building electrical room and to the CoGen Building.
i) Add/edit mechanical and electrical sheets for Blower Buildings 1 and 2, the Thickening Building, the chiller yard, and the CoGen building showing HVAC equipment.
i) Perform the following Structural Engineering Services i) Construction Administration Phase – MEP.
ii) Schedule a Project Manager and all necessary team members to attend a total of three (1) on-site construction progress meeting. During on-site meeting, Project Manager and team shall:
• Observe the completed subtasks and witness any work-in-progress. • Review installation progress and ensure that the contractor is on schedule.
• Maintain a punch list of incomplete work.
• Provide field reports of the findings during site visits. iii) Review, respond, and approve all submittal material and shop drawings for substantial conformity with the intent of the contract plans and specifications. iv) Review and respond to MEP and structural related requests for information and clarification pertaining to Consultant's design. Detailed information and technical guidance shall be provided so that all requests are satisfied. v) Review close-out documents including but not limited to warranties, manuals, and as-builts.
j) System Commissioning Management – MEP
i) Attend the system and equipment testing and commissioning. ii) Test results will be documented in a punch list with responsibilities for FIN:201-10\jr\H:\COMMON\Council\2026\Facilities\08252026CCMtg\CI 5647 & CI 5662 Glumac Consulting Services 13365- 2023A1.docx
correcting shortcomings assigned to the appropriate parties. iii) Construction Close-out will include a complete final on-site walk-through to ensure all of the items on the punch list were addressed.
***Scope to be a $0 deliverable, to be incorporated into a bid set suitable for the public bid process. Bid support to be a $0 deliverable.
DESIGN & CONSTRUCTION SCHEDULE
Consultant is expected to adhere to the following schedule, beginning 2-3 weeks after receiving Authorization to Proceed from the City:
PHASE WEEKS
Evaluation & Documentation of Existing Systems 6
Construction Documents 8
Bid Support 6
Construction Administration 18
System Commissioning 4
Construction Close-out 2
It is assumed that the design schedule is continuous and there will be no significant delays between phases. Project delays caused by the City exceeding 60 days will require a Re- mobilization of Staff Fee that will be submitted as an Additional Service Request prior to the restart of the project.
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EXHIBIT B-1
GLUMAC
Mechanical Engineering Consultant for Upgrades at Hill Canyon Treatment Plant and Los Robles Golf Course CI 5647 & CI 5662
SCHEDULE OF FEES
ENGINEERING SERVICES
Review, Design
SUMMARY OF PROJECT COSTS
Los Robles Greens $60,913
Hill Canyon Treatment Plant $43,087
Extra Services (Both Sites) $6,000
Contract Not-To-Exceed Total $110,000
SUMMARY OF COST BY PROJECT
Los Robles Greens
MEP Design Drawings $12,220
*Construction Administration $40,940
MEP Subtotal $53,160
*Structural Construction Admin $ 7,365
Structural Subtotal $ 7,365
Estimated Reimbursables $ 388
Not-to-exceed Total for
Los Robles Greens Services
$60,913
*Construction Administration costs are listed as Not to Exceed amounts and shall be billed hourly based on the rates listed below. Consultant shall bill by percentage completed for Hill Canyon Treatment Plant
MEP Design Drawings $13,700
*Construction Administration $22,930
MEP Subtotal $ 36,630
*Structural Construction Admin $ 5,570
Structural Subtotal $ 5,570
Estimated Reimbursables $ 887
Not-to-exceed Total for Hill Canyon Services $ 43,087 FIN:201-10\jr\H:\COMMON\Council\2026\Facilities\08252026CCMtg\CI 5647 & CI 5662 Glumac Consulting Services 13365- 2023A1.docx
each phase on a monthly basis and describe the work performed (including, if applicable, a list of hours worked by personnel classification), the percentage of the task completed during the billing period, the cumulative percentage completed for each task and the total cost of that work during the preceding billing month.
REIMBURSABLE EXPENSES
Estimated reimbursable expenses are shown above for each phase and will be billed at
1.1 times the cost. Anticipated reimbursable expenses include, but are not limited to travel expenses, which includes, but are not limited to hotel, lodging, meals, cost of travel (airline tickets or mileage costs at $0.55 per mile), car rental, etc.
Costs not considered reimbursable: In-house black & white or color reproductions smaller than 11“ x 17“ on standard paper; phone calls within the State of California; and standard USPS first-class mail.
STANDARD HOURLY BILLING RATES
ENGINEERING DESIGN
President ......................................................................................................... $475.00 Vice President ................................................................................... $250.00-$350.00 Project Manager ................................................................................ $205.00-$250.00 Project Engineer ................................................................................ $175.00-$250.00 Designer ............................................................................................ $150.00-$215.00 BIM .................................................................................................... $135.00-$215.00 CAD ................................................................................................... $115.00-$150.00 Construction Manager ....................................................................... $175.00-$225.00
SUSTAINIBILITY CONSULTING
Integrated Design .............................................................................. $150.00-$230.00 Energy Modeling ............................................................................... $150.00-$235.00 CFD Modeling ................................................................................... $150.00-$250.00 Lighting Design ................................................................................. $150.00-$230.00 Tech Integration Design .................................................................... $175.00-$235.00 Commissioning .................................................................................. $150.00-$235.00
PROJECT ADMINISTRATION
Project Coordinator ......................................................................................... $175.00 Project Administrator ....................................................................................... $150.00 Project Assistant ............................................................................................. $100.00
1 CAO:650-90/tmn/Legal Files\Levine Act - Applications
LEVINE ACT DISCLOSURE FORM
California Government Code section 84308 (Levine Act) prohibits any Thousand Oaks City Council member from participating in any action related to a contract, agreement, or franchise agreement (excluding labor or competitively bid contracts) if the Council member receives a campaign contribution totaling more than $ (aggregated ) from the party to the contract, agreement or franchise agreement, their agents, or any financially interested participant who actively supports or opposes the matter within the previous twelve (12) months.
Council members must also disclose any eligible campaign contribution received on the record of the proceeding.
Council members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $ (aggregated) from a party, their agent/representative, or a financially interested participant during a proceeding and for 12 months following the date a final decision is made. In addition, a party, their agent/representative, or a financially interested participant is prohibited from contributing more than $ (aggregated) to a Council member during a proceeding and for 12 months following the date a final decision is made.
The Levine Act also requires parties to certain contracts, agreements, or franchise agreements to disclose any campaign contribution over $ (aggregated) within the preceding twelve (12) months by the party to the agreement, contract, or franchise agreement and their agents. The Levine Act does not apply to competitively bid, labor, or personal employment contracts.
The Levine Act (Gov Code § 84308) DOES NOT apply to this proposal/application The Levine Act (Gov Code § 84308) DOES apply to this proposal/application and the required disclosure is set forth below:
1. Have you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $ (aggregated) to any council member in the 12 months preceding the date you submitted your proposal/application, the date you completed this form, or the anticipated date of any Council action related to this proposal/application? YES
NO
Council Member Name Payee Name Payment Date Payment Amount EXHIBIT C-1
2. Do you or your organization, or any agency or representative on behalf ofyou or your organization, anticipate or plan to make any campaigncontributions of more than $ (aggregated) to any City Council memberin the 12 months following any City Council action related to thisproposal/application? ** There may be legal restrictions on makingcontributions during the 12 months following City Council Action. Itis recommended that you consult with your own legal counselregarding the requirements of law. YES NO Council Member Name Payee Name Payment Date Payment Amount Answering YES to either question above does not preclude the City of Thousand Oaks from entering into or taking any subsequent action related to this proposal/application. However, it may preclude the identified Council member(s) from participating in any actions/decisions related to this proposal/application. ____________ ______________________________ _______________________ Date Printed Name/Title of Authorized Name of Business/Legal Representative Entity ____________________________________________________________________________ Signature You must submit a supplemental form if you make any new reportable contribution(s) while the proposal/application is being considered* 2 CAO:650-90/tmn/Legal Files\Levine Act - Applications