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DocuSign Envelope ID:98CAB32E-1814-4C97-B61E-B14BE79B81EA <br /> Orange County,North Carolina <br /> Lake Orange Erosion Control Barrier Replacement <br /> created by the State Treasurer pursuant to N.C.G.S. 143-6A-4, Iran Divestment Act Certification. <br /> Contractor/vendor shall not utilize any subcontractor that is identified on the list. <br /> Respectfitlly submitted this <br /> T� <br /> day of t7ECe'�grQ 2021 <br /> i� LI,G d6a Sanr-fjL,l <br /> (Name of Firm or Corporation making Bid) <br /> 13� � � 1�--► <br /> WITNESS: <br /> (Proprietorship or Partnership) <br /> Title: <br /> 8 (Owner. Partner, or Corporation <br /> R reside r Vice President Only) <br /> v Address: 701 �i0IsoA•4TC ('c�•►TE.L Q <br /> w -5/rTC:5 !o! <br /> —R Er A!C V (An7 <br /> Affix C bove License Number: Sig <br /> ATTEST; <br /> By: <br /> Title: Air yIfA m`T 5_�Ue Al <br /> (Corporation Secretary or Assistant Secretary Only) <br /> Bid Proposal Form 004000-3 <br />