Appears in 1 contract

Samples: Power Purchase Agreement (Ormat Technologies, Inc.)

Appears in 1 contract

DECLARATION UNDER PENALTY OF PERJURY. I understand that I am required to ~~permit~~ pennit the City of Los Angeles access to and upon request, must provide certified copies of all company records pertaining to benefits, policies and practices for the purpose of investigation or to ascertain compliance with the Equal Benefits Ordinance. Furthermore, I understand that failure to comply may be deemed a material breach of any City contract by the Awarding Authority; the Awarding Authority may cancel, terminate or suspend in whole or in part, the contract; monies due or to become due under a contract may be retained by the City until compliance is achieved. The City may also pursue any and all other remedies at law or in equity for ~~any~~ aity breach. The City may use the failure to comply with the Equal Benefits Ordinance as evidence against the Contractor in actions taken pursuant to the provisions of the Los Angeles Administrative Code Section 10.40, et seq., Contractor Responsibility Ordinance. Beacon Solar 3, LLC will comply with the Equal Benefits Ordinance requirements Company Name as indicated above prior to executing a contract with the ~~City~~ City' of Los Angeles and will comply for the entire duration of the ~~contract(s~~contracts). I declare under penalty ~~of perjury~~ ofpeijury under the laws of the State of California that the foregoing is true and correct, and that I am authorized to bind this entity contractually. ~~Executed this day of ,~~ m in the year 20 16 , at Salt Lake City UT (City) (State) 0000 Xxxxx 0000 Xxxx, Xxxxx 000 Xxxx Xxxxxxx Name of Signatory (please print) Authorized Person Xxxx Xxxx Xxxx, Xxxx 00000 . City, State, Zip Coda 00-0000000 Title ~~EIN~~EJN/TIN ~~CITY OF LOS ANGELES PLEDGE OF COMPLIANCE WITH CONTRACTOR RESPONSIBILITY ORDINANCE~~ Los Angeles Administrative Code (LAAC) Section 10.40 et seq. (Contractor Responsibility Ordinance) provides that, unless specifically exempt, City contractors working under service contracts of at least $25,000 and three months, contracts for services and for purchasing goods and products that involve a value in excess of twenty-five thousand dollars ($25,000) and a term in excess of three months are covered by this Article; and construction contracts of any amount; public lessees; public licensees; and certain recipients of City financial assistance or City grant funds, shall comply with ail applicable provisions of the Ordinance, Upon award of a City contract, public lease, public license, financial assistance or grant, the contractor, public lessee, public licensee, City financial assistance recipient, or grant recipient, and any its subcontractors), shall submit this Pledge of Compliance to the awarding authority. The contractor agrees to comply with the Contractor Responsibility Ordinance and the following provisions: (a) To comply with all federal, state, and local laws in the performance of the contract, including but not limited to laws regarding health and safety, labor and employment, wage and hours, and licensing laws, which affect employees, (b) To notify the awarding authority within 30 calendar days after receiving notification that any governmental agency has initiated an investigation which may result in a finding that the contractor did not comply with any federal, state, or local law in the performance of the contract, including but not limited to laws regarding health and safety, labor and employment, wage and hours, and licensing laws, which affect employees. (c) To notify the awarding authority within 30 calendar days of all findings by a governmental agency or court of competent jurisdiction that the contractor has violated any federal, state, or local law in the performance of the contract, including but not limited to laws regarding health and safety, labor and employment, wage and hours, and licensing laws which affect employees. (d) If applicable, to provide the awarding authority, within 30 calendar days, updated responses to the Responsibifity Questionnaire if any change occurs which would change any response contained within the Responsibility Questionnaire and such change would affect the contractor's fitness and ability to continue the contract. (e) To ensure that subcontractors working on the City agreement (including contractors or subcontractors of a public lessee, licensee, sublessee, or sublicensee that perform or assist in performing services on the leased or licensed premises) shall comply with all federal, state, and local laws in the performance of the contract, including but not limited to laws regarding health and safety, labor and employment, wage and hours, and licensing laws, which affect employees. (f) To ensure that subcontractors working on the City agreement (including contractors or subcontractors of a public lessee, licensee, sublessee, sublicensee that perform or assist in performing services on the leased or licensed premises) submit a Pledge of Compliance. (g) To ensure that subcontractors working on the City agreement (including contractors or subcontractors of a public lessee, licensee, sublessee, or sublicensee that perform or assist in performing services on the leased or licensed premises) shall comply with paragraphs (b) and (c). Failure to complete and submit this form to the Awarding Authority may result In withholding of payments by the City Controller, or contract termination. Beacon Solar 3, 000 Xxxxx 0000 Xxxx, Xxxx Xxxx Xxxx, XX 00000 Phone Number 000-000-0000 i xxx of Officer or Authorized Representative Date Xxxx Xxxxxxx, Authorized Person Print Name and Title of Officer or Authorized Representative Department of Water and Power Awarding City Department SRIS/CRO-3, Pledge of Compliance (Rev. 5/07/2014) . XX-00-000 Xxxxxxxx Xxxxxx Los Angeles Administrative Code (LAAC) Section 10.40 et seq. (Contractor Responsibility Ordinance) provides that, unless specifically exempt, City contractors working under service contracts of at least $25,000 and three months, contracts for services and for purchasing goods and products that involve a value in excess of twenty-five thousand dollars ($25,000) and a term in excess of three months are covered by this Article; and construction contracts of any amount; public lessees; public licensees; and certain recipients of City financial assistance or City grant funds, shall comply with all applicable provisions of the Ordinance. Upon award of a City contract, public lease, public license, financial assistance or grant, the contractor, public lessee, public licensee, City financial assistance recipient, or grant recipient, and any its subcontractor(s), shall submit this Pledge of Compliance to the awarding authority. The contractor agrees to comply with the Contractor Responsibility Ordinance and the following provisions: (a) To comply with all federal, state, and local laws in the performance of the contract, including but not limited to laws regarding health and safety, labor and employment, wage and hours, and licensing laws, which affect employees. (b) To notify the awarding authority within 30 calendar days after receiving notification that any governmental agency has initiated an investigation which may result in a finding that the contractor did not comply with any federal, state, or local law in the performance of the contract, including but not limited to laws regarding health and safety, labor and employment, wage and hours, and licensing laws, which affect employees. (c) To notify the awarding authority within 30 calendar days of all findings by a governmental agency or court of competent jurisdiction that the contractor has violated any federal, state, or local law in the performance of the contract, including but not limited to laws regarding health and safety, labor and employment, wage and hours, and licensing laws which affect employees. (d) If applicable, to provide the awarding authority, within 30 calendar days, updated responses to the Responsibility Questionnaire if any change occurs which would change any response contained within the Responsibility Questionnaire and such change would affect the contractor's fitness and ability to continue the contract. (e) To ensure that subcontractors working on the City agreement (including contractors or subcontractors of a public lessee, licensee, sublessee, or sublicensee that perform or assist in performing services on the leased or licensed premises) shall compiy with all federal, state, and local laws in the performance of the contract, Including but not limited to laws regarding health and safety, labor and employment, wage and hours, and licensing laws, which affect employees. (f) To ensure that subcontractors working on the City agreement (including contractors or subcontractors of a public lessee, licensee, sublessee, sublicensee that perform or assist in performing services on the leased or licensed premises) submit a Pledge of Compliance. (g) To ensure that subcontractors working on the City agreement (including contractors or subcontractors of a public lessee, licensee, sublessee, or sublicensee that perform Or assist in performing services on the leased or licensed premises) shall comply with paragraphs (b) and (c). a ** Company Name, Signature of icer or Aut|wfzi^Representative Date Print Nsfme and Title of Officer or Authorized Representative Awarding City Department Contract Number SRIS/CRO-3, Pledge of Compliance (Rev. 5/07/2014) CITY OF LOS ANGELES CONTRACTOR CODE OF CONDUCT The City of Los Angeles has long supported the premise that employers should fairly compensate employees, that the health and safety of workers should be protected, and that no form of discrimination or abuse should be tolerated. Experience indicates that laws and regulations designed to safeguard basic tenets of ethical business practices are disregarded in some workplaces, commonly referred to as “sweatshops." In its role as a market participant that procures equipment, goods, materials and supplies, the City seeks to protect its interests by assuring that the integrity of the City’s procurement process is not undermined by contractors who engage in sweatshop practices and other employment practices abhorrent to the City. When the City inadvertently contracts with these contractors, the City’s ethical contractors are placed at a distinct competitive disadvantage. Many times ethical contactors are underbid by unscrupulous contractors in competition for City contracts. These ethical contractors may be dissuaded from participating in future procurement contracts. The City’s proprietary contracBng interests are served by doing business with contractors who make a good faith effort to ensure that they and their subcontractors shun sweatshop practices and adhere to workplace and wage laws. Seeking to protect these municipal interests, the City requires that all contractors subject to the Sweat-free Procurement Ordinance certify that they and, to the best of their knowledge, their subcontractors will comply with the City’s Contractor Code of Conduct and to promise the following: (d) To comply with all applicable wage, health, labor, environmental and safety laws, legal guarantees of freedom of association, building and Are codes, and laws and ordinances relating to workplace and employment discrimination. To comply with all human and labor rights and labor obligations that are imposed by treaty or law on the country in which the equipment, supplies, goods or materials are made or assembled, including but not limited to abusive forms of child labor, slave labor, convict or forced labor, or sweatshop labor. To take good faith measures to ensure, to the best of toe contactor’s knowledge, that the contactor’s subcontractors also comply with the City’s Contactor Code of Conduct. To pay employees working on contracts for garments, uniforms, foot apparel, and related accessories a procurement living wage, meaning for domestic manufacturers a base hourly wage adjusted annually to the amount required to produce, for 2,080 hours worked, an annual income equal to or greater than the U.S. Department of Health and Human Services most recent poverty guideline for a family of three plus an additional 20 percent of the wage level paid either as hourly wages or health benefits. For manufacturing operations in countries other than the United States, a procurement living wage which is comparable to the wage for domestic manufacturers as defined above, adjusted to reflect the country’s level of economic development by using foe World Bank’s Gross National Income Per Capita Purchasing Power index. CERTIFICATION UNDER PENALTY OF PERJURY undent* " * " ' htractor Code of Conduct and agree to amply with its requirements. Print Name and Title ofAuthorized Representative Print Company Name, Address and Phone Number ! ~~ " ' ’ Unless approved for an exemption, contractors under contracts primarily for the furnishing of services to or for the City and that involve an expenditure in excess of $25,000 and a contract term of at least three (3) months, lessees and licensees of City property, and certain recipients of City financial assistance, shall comply with the provisions of Los Angeles Administrative Code Sections 10.37 et seq., Living Wage Ordinance (LWO) and 10.36 et seq,, Service Contractor Worker Retention Ordinance (SCWRO). Bidders/Proposers shall refer to Attachment/Appendix “Living Wage Ordinance and Service Contractor Worker Retention Ordinance” for further information regarding the requirements of the Ordinances. Bidders/Proposers who believe that they meet the qualifications for one of the exemptions described in the LWO List of Statutory Exemptions shall apply for exemption from the Ordinance by submitting with their proposal the Bidder/Contractor Application for Non-Coverage or Exemption (Form OCC/LW-10), or the Non-Profit/One- Person Contractor Certification of Exemption (OCC/LW-13). The List of Statutory Exemptions, the Application and the Certification are included in the Attachment/Appendix. LWO/SCWRO RFP Language 08/10

Appears in 1 contract

Samples: Power Purchase Agreement

DECLARATION UNDER PENALTY OF PERJURY. I understand that I am required to permit the City of Los Angeles access to and upon request, must provide certified copies of all company records pertaining to benefits, policies and practices for the purpose of investigation or to ascertain compliance with the Equal Benefits Ordinance. Furthermore, I understand that failure to comply with LAAC Section 10.8.2.1 et seq., Equal Benefits Ordinance may be deemed a material breach of any City contract by the Awarding Authority~~; the~~ . The Awarding Authority may cancel, terminate or suspend in whole or in part, the contract; monies due or to become due under a contract may be retained by the City until compliance is achieved. The City may also pursue any and all other remedies at law or in equity for any breach. The City may use the failure to comply with the Equal Benefits Ordinance as evidence against the Contractor in actions taken pursuant to the provisions of the ~~Los Angeles Administrative Code~~ LAAC Section 10.40, et seq., Contractor Responsibility Ordinance. ~~will~~ Vt N /ti /nfcrtMyWill comply with the Equal Benefits Ordinance requirements Company Name • as indicated above prior to executing a contract with the City of Los Angeles and will comply for the entire duration of the ~~contract(s~~contracts). I declare under penalty of perjury under the laws ~~of the~~ ofthe State of California that the foregoing is true and correct, and that I am authorized to bind this entity contractually. Executed ~~this~~ thi: day of , JiQ wK&v- in the year 20 1 Co , at [jiW'uJA I 1C CL Signature Mailing Address Name of Signatory (please print) City, ~~Title~~ State, Zip Code Lj v ) W2. L V/v-iA (for-u.«r 1332-13123 EIN/~~TIN CITY OF LOS ANGELES PLEDGE OF COMPLIANCE WITH CONTRACTOR RESPONSIBILITY ORDINANCE Los Angeles Administrative Code~~ TLN Form OCC/LAWA EBO-Affidovit (~~LAAC~~Rev 5/20/13) ~~Section 10.40 et seq~~2 First Source Hiring Pursuant to Resolution No. ~~(Contractor Responsibility Ordinance) provides that~~22674 adopted by Board of Airport Commissioners on April 18, ~~unless specifically exempt~~2005, ~~City contractors working under service contracts of at least $25,000~~ any contract awarded July 1, 2005 and three months, contracts for services and for purchasing goods and products that involve a value in excess of twenty-five thousand dollars ($25,000) and a term in excess of three months are covered by this Article; and construction contracts of any amount; public lessees; public licensees; and certain recipients of City financial assistance or City grant funds, thereafter shall ~~comply with all~~ be subject to the applicable provisions of the ~~Ordinance~~First Source Hiring Program (FSHP) for LAX airport jobs. ~~Upon award~~ This program will provide early access to targeted applicants for available LAX airport jobs, and employers will receive prompt, cost-free referrals of ~~a City contract~~qualified and trained applicants. All Contractors, ~~public lease~~Lessees, ~~public license~~Licensees, ~~financial assistance~~ and Construction Contractors with non-trade jobs, with new, amended, or ~~grant~~renewed contracts will be required to participate in this program. As such, the ~~contractor~~FSHP will be incorporated as a material term of all LAX airport contracts, ~~public lessee~~lease agreements and licensing or permitting agreements. LAX employers with open non-construction positions must contact the FSHP, ~~public licensee, City financial assistance recipient, or grant recipient,~~ register their company and ~~any its subcontractor(s), shall submit this Pledge of Compliance~~ post their positions on the Applicant Tracking System (ATS) prior to posting their positions to the ~~awarding authority~~general public. ~~The contractor agrees~~ Failure to comply with ~~the Contractor Responsibility Ordinance~~ this contract provision may result in liquidated damages of $1,000.00. For additional information regarding First Source Hiring Program please contact: Business and Job Resources Center, First Source Hiring Program, 0000 X. Xxxxxxx Xxxx., 0xx Xxxxx, Xxx Xxxxxxx, XX 00000, (000) 000-0000, (000) 000-0000 fax., web: xxx.xxxx.xxx/xxxx. Insurance NAME: AGREEMENT / ACTIVITY: TERM: LAWA DIVISION: Commercial Development Group The insured must maintain insurance coverage at limits normally required of its type operation; however, the following ~~provisions:~~coverage noted with an "X" is the minimum required and must be at least the level of the limits indicated. All limits are per occurrence unless otherwise specified.

Appears in 1 contract

Samples: Airline Premier Passenger Lounge Space Lease and License Agreement

Appears in 1 contract

Samples: Lease Agreement

DECLARATION UNDER PENALTY OF PERJURY. Each person signing below acknowledges and understands that this form is an official document sanctioned by the Court that presides over the legal action entitled In Re Sulzer Hip Prosthesis and Knee Prosthesis Product Liability Litigation. Submitting this Claim Form to the Claims Administrator is equivalent to filing it with the Court. After reviewing the information that has been provided on this form, including information, if applicable, that was supplied by a Board-Certified physician and/or an attorney, each person signing this form declares under penalty of perjury that all of the information provided in this form is true and correct to the best of that person's knowledge and belief. / / --------------------------------------------------- ------------------- (Signature of APR) (Date - MM/DD/YYYY) OR / / --------------------------------------------------- ------------------- (Signature of Each Representative Claimant, if any) (Date - MM/DD/YYYY) Mail this Claim Form and all attachments to: Claims Administrator Sulzer Settlement Trust P.O. Box 94558 Cleveland, Ohio 44101-4558 XXXXXX XXXX - 00 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND OTHER HEALTH INFORMATION I hereby authorize the use or disclosure of my individually identifiable health information and medical records as described below. I understand that this authorization is voluntary. I understand that because the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations, but it will be subject to the confidentiality provisions of the Settlement Agreement. INFORMATION AUTHORIZED FOR RELEASE: I authorize the release of the following records/recordings to the Sulzer Settlement Trust: any medical records that pertain or relate to the diagnosis, care or treatment of any disease, condition or procedure related to or arising from any implantation in the Patient/Affected Product Recipient of a hip or knee prosthesis(es) including information about the undersigned Affected Product Recipient or Patient, his/her hip or knee prosthesis(es), the hospital(s) where and surgeon(s) who made, provided, gave or performed any diagnosis, care treatment, or procedure, the manufacturer, product and lot numbers of any hip or knee prostheses, any surgery(ies) associated with the hip or knee prosthesis(es), the date(s) and nature of any medical treatment associated with the implant(s) of the hip or knee prosthesis(es), hospital reports including pre-admission and admission histories, treating and implanting surgeons' records, physical examinations, hospital discharge summaries, operative reports and nursing notes, anesthesia records, pathology reports, results/reports of all objective quantitative studies performed, progress notes, prescription records, medical records of cardiothoracic surgeons and/or cardiologists or neurologist, death summaries, certificate of death or autopsy report, and any billing records and/or payment records. PATIENT/AFFECTED PRODUCT RECIPIENT IDENTIFICATION: ----------------------------- ---------------- ------------------------- (First Name) (Middle Initial) (Last Name) / / - - ------------------------- ------------------------------- (Birth Date MM/DD/YYYY) (Social Security Number) -------------------------------------------------------------------------------- (List all other names that the APR uses or has used during the last ten years) PERSONS/ORGANIZATIONS PROVIDING THE INFORMATION: Any organization maintaining records described above that are necessary to adjudicate the relevant claim filed under the Settlement Agreement. FORWARD THE ABOVE RECORDS TO: Claims Administrator Sulzer Settlement Trust P.O. Box 94558 Cleveland, OH 44101-4558 ================================================================================ I understand that this authorization will expire three (3) years from the date I sign this document as indicated below. In addition, I understand that I am may revoke this authorization at any time by notifying the providing organization in writing, but if I do revoke this authorization it will not have any effect on any actions any providing organization took before it received the revocation. Also, this authorization does not authorize the disclosure of any information other than the items referenced above. / / ---------------------------------------------------------------------------- ----------------- Signature of Patient/Affected Product Recipient or Authorized Representative Date (MM/DD/YYYY) ------------------------------------------------------------------------------------------------------ Printed Name of Authorized Representative (if applicable) ------------------------------------------------------------------------------------------------------- Relationship of Representative to Patient/Affected Product Recipient (if applicable) ORANGE FORM - 11 EXHIBIT D ================================================================================ PHYSICIAN DECLARATION FORM Sulzer Orthopedics Inc., Sulzer Medica AG (collectively "Sulzer") and Sulzer AG have agreed to settle certain legal claims that are pending xx xxxx xay be brought against them relating to two implantable medical devices that Sulzer marketed, the Inter-Op(TM) Acetabular Shell and the Natural Knee II(R) Tibial Baseplate ("Affected Products"). Affected Product Recipients ("APRs") are those persons who have been implanted with one or more Affected Products. To register for benefits under the Sulzer Class Action Settlement Agreement, APRs must submit Claim Forms. To qualify for certain benefits, APRs also must submit this "Physician Declaration," wherein a treating physician(1) is required to ~~permit~~ certify that an APR has/had a particular medical condition. These conditions are set forth in the ~~City~~ various Claim Forms, and include surgical removal and/or replacement of ~~Los Angeles access to and upon request, must provide certified copies of all company records pertaining to benefits, policies and practices~~ an Affected Product for ~~the purpose of investigation~~ a reason other than trauma ("Affected Product Revision Surgery" or to ascertain compliance with the Equal Benefits Ordinance. Furthermore, I understand that failure to comply may be deemed a material breach of any City contract by the Awarding Authority; the Awarding Authority may cancel, terminate or suspend in whole or in part, the contract; monies due or to become due under a contract may be retained by the City until compliance is achieved. The City may also pursue any and all other remedies at law or in equity for any breach. The City may use the failure to comply with the Equal Benefits Ordinance as evidence against the Contractor in actions taken pursuant to the provisions of the Los Angeles Administrative Code Section 10.40, et seq., Contractor Responsibility Ordinance. will comply with the Equal Benefits Ordinance requirements Company Name as indicated above prior to executing a contract with the City of Los Angeles and will comply for the entire duration of the contract(s"APRS"). ~~I declare under penalty~~ In completing this "Physician Declaration," you may consider the APR's medical records, charts, reports, diagnostic films, medical history or other sources of ~~perjury under~~ information that physicians regularly and routinely rely upon in their practice. By signing this Form, you certify that all opinions set forth in this "Physician Declaration" are offered to a reasonable degree of medical certainty. If this "Physician Declaration" is being used to supplement a prior Physician Declaration form, you only need to provide information which relates to a medical condition that has changed since the ~~laws of~~ date on which any prior EIF Benefits Claim Form was completed. 1. PHYSICIAN'S MEDICAL BACKGROUND --------------------------- -------- --------------------------- (First Name) (Middle Initial) (Last Name) ------------------------------------------------------------------------ (Office Address) - ---------------------------- -------- ------------------------------- (City) (State) (Zip Code) ( ) - ( ) - ------------------------------ ------------------------------- (Area Code & Telephone Number) (Fax Area Code & Number) Check whether you are: [ ] A Board-Certified Orthopedic surgeon; or [ ] A Board-Certified Cardiologist; or [ ] A Board-Certified Cardiothoracic surgeon; or [ ] A Board-Certified Neurologist; or [ ] A Board-Certified Neurosurgeon; or [ ] Other --------------------------------- YOU MUST ATTACH A COPY OF YOUR CURRENT BOARD CERTIFICATION TO THIS DECLARATION. ---------- (1) The Claims Administrator MAY accept a "Physician Declaration" supplied by a Board-Certified orthopedic surgeon, neurologist, neurosurgeon, cardiologist and/or cardiothoracic surgeon ONLY where the ~~State of California that the foregoing~~ treating physician is ~~true and correct, and that I am authorized~~ unavailable to ~~bind this entity contractually~~certify these responses. Executed this day of , in the year 20 , at , Title EIN/TIN CITY OF LOS ANGELES PLEDGE OF COMPLIANCE WITH CONTRACTOR RESPONSIBILITY ORDINANCE Los Angeles Administrative Code (LAAC) Section 10.40 et seq. (Contractor Responsibility Ordinance) provides that, unless specifically exempt, City contractors working under service contracts of at least $25,000 and three months, contracts for services and for purchasing goods and products that involve a value in excess of twenty-five thousand dollars ($25,000) and a term in excess of three months are covered by this Article; and construction contracts of any amount; public lessees; public licensees; and certain recipients of City financial assistance or City grant funds, shall comply with all applicable provisions of the Ordinance. Upon award of a City contract, public lease, public license, financial assistance or grant, the contractor, public lessee, public licensee, City financial assistance recipient, or grant recipient, and any its subcontractor(s), shall submit this Pledge of Compliance to the awarding authority. The contractor agrees to comply with the Contractor Responsibility Ordinance and the following provisions:PHYSICIAN DECLARATION - 1

Appears in 1 contract

Samples: Class Action Settlement Agreement (Sulzer Medica LTD)

Common use of DECLARATION UNDER PENALTY OF PERJURY Clause in Contracts