HomeMy WebLinkAboutContract 49141-FP1 City Secretary 49141 -FP1
Contract No.
FORT WORTH® nate Received Ju126,2018
59 401
NOTICE OF PROJECT COMPLETION
(Developer Projects)
The Transportation and Public Works Department upon the recommendation of the Project
Manager has accepted the following project as complete:
Project Name: PRIMROSE CROSSING—PHASE 4
City Project No.: 100534
Improvement Type(s): ® Paving ❑ Drainage ❑ Street Lights ❑ Traffic Signals
Original Contract Price: $617,690.45
Amount of Approved Change Order(s):
Revised Contract Amount:
Total Cost of Work Complete: $617,690.45
° Jul 202 2018
sloe raylnr(J 20,20301
Contractor Date
Project Coordinator
Title
Gilco Contracting,Inc.
Company Name
1 �
James Divar(Jul 24,201B) Ju124, 2018
Pro'ect In ector Date
Hhal Jaafari(Jul 1018] Jul 25, 2018
Project Manager Date
al ° Jul 25, 2018
Evelyn ertz(Ju125,2038)
CFA Manager Date
Susan Nanis(Ju125,2038) Jul 25�, 2018
Asst. City Manager Date
age 1of2
OFFICIAL RIBCE
CITY SECRET
FT.WORTH,
Notice of Project Completion
Project Name: PRIMROSE CROSSING — PHASE 4
City Project No.: 100534
City's Attachments
Final Pay Estimate
Change Order(s): ❑ Yes ❑x N/A
Contractor's Attachments
Affidavit of Bills Paid -
Consent of Surety
Statement of Contract Time
.Contract Time: 160 CD Days Charged: 380
Work Start Date: 6/27/2017 Work Complete Date: 7/11/2018
Page 2 of 2
G
oo53</
City Project Numbers 100534 DOE Number 5340
Contract Name PRIMROSE CROSSING-PHASE 4 Estimate Number I
Contract Limits Payment Number 1
Project Type PAVING For Period Ending 7/20/2018
Project Funding
Project Manager NA City Secretary Contract Number
Inspectors DICKINSON / DIVER Contract Date jI
Contractor GILCO CONTRACTING,INC. Contract Time 160 CD
6331 SOUTHWEST BLVD. Days Charged to Date 380 CD
BENBROOK, TX 76132-1063 Contract is .000000 Complete
CITY OF FORT WORTH
SUMMARY OF CHARGES
Line Fund Account Center Amount Gross Retainage Net
Funded
k
Total Cost of Work Completed $617,690.45
Less %Retained $0.00
Net Earned $617,690.45
Earned This Period $617,690.45
Retainage This Period $0.00
!
Less Liquidated Damages y
0 Days @ $0.00 /Day $0.00 !
LessPavement Deficiency $0.00 {
Less Penalty $0.00
Less Previous Payment $0.00
Plus Material on Hand Less 15% $0.00
Balance Due This Payment $617,690.45
Friday,July 20,2018 Page 4 of 4 !;
C�
f
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name PRIMROSE CROSSING-PHASE 4
Contract Limits
Project Type PAVING
City Project Numbers 100534
DOL Number 5340
Estimate Number 1 Payment Number 1 For Period Ending 7/20/2018
CD
City Secretary Contract Number Contract Time 16aD
Contract Date Days Charged to Date 380
Project Manager NA Contract is 100.00 Complete
Contractor GiLCO CONTRACTING,INC.
6331 SOUTHWEST BLVD.
BENBROOK, TX 76132-1063
Inspectors DICKINSON / DIVER
Friday,July 20,2018 Page 1 of 4
City Project Numbers 100534 DOE Number 5340
Contract Name PRIMROSE CROSSING-PHASE 4 Estimate Number 1
Contract Limits Payment Number 1
Project Type PAVING For Period Ending 7/20/2018
Project Funding
UNIT IV:PAVING IMPROVEMENTS
Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed
No. Quanity Total Quanity Total
----------------------- -- - ------------
1 HYDRATED LIME(30 LBS/SY) 239 TN $155.00 $37,045.00 239 $37,045.00
2 6"LIME TREATMENT 15938 SY $2.55 $40,641.90 15938 $40,641.90
3 6"CONC PVMT 14954 SY $32.20 $481,518.80 14954 $481,518.80
4 4"CONC SIDEWALK 5081 SF $4.75 $24,134.75 5081 $24,134.75
5 BARRIER FREE RAMP TYPE R-1 3 EA $1,950.00 $5,850.00 3 $5,850.00
6 BARRIER FREE RAMP TYPE M-2 3 EA $1,900.00 $5,700.00 3 $5,700.00
7 BARREIR FREE RAMP TYPE P-1 3 EA $1,600.00 $4,800.00 3 $4,800.00
8 REMOVE BARRIER AND CONNECT TO 3 EA $500.00 $1,500.00 3 $1,500.00
EXISTING PAVEMENT
9 CONCRETE PAVEMENT HEADER I EA $300.00 $300.00 l $300.00
10 STOP SIGNS 1 EA $500.00 $500.00 1 $500.00
11 STREET NAME BLADE 24 EA $150.00 $3,600.00 24 $3,600.00
12 STREET SIGN POLE 6 EA $500.00 $3,000.00 6 $3,000.00
13 PAYMENT PERFORMANCE&MAINTENANCE 1 LS $9,100.00 $9,100.00 1 $9,100.00
BONDS
i
Sub-Total of Previous Unit $617,690.45 $617,690.45
Friday,July 20,2018 Page 2 of 4
City Project Numbers 100534 DOE Number 5340
Contract Name PRIMROSE CROSSING-PHASE 4 Estimate Number I
Contract Limits Payment Number I
Project Type PAVING For Period Ending 7/20/2018
Project Funding
s%
Contract Information Summary
Original Contract Amount $617,690.45
Chane Orders
Total Contract Price $617,690.45
Total Cost of Work Completed $617,690.45
Less %Retained $0.00
Net Earned $617,690.45
Earned This Period $617,690.45
Retainage This Period $0.00 ?i
Less Liquidated Damages
Days @ /Day $0.00
LessPavement Deficiency $0.00
Less Penalty $0.00
Less Previous Payment $0.00
Plus Material on Hand Less 15% $0.00
Balance Due This Payment $617,690.45
Friday,July 20,2018 Page 3 of 4
GILCO CONTRACTING, INC.
TRANSMITTAL LETTER
PROJECT:Primrose Crossing,Phase 4
PROJECT NO.: 1209
DATE:May 30,2018
TO: City of Fort Worth
8851 Camp Bowie W.Blvd.
Fort Worth,Texas 76116
We transmit:
(X)Herewith ( )Under Separate cover via
For Your:
( )Approval ( )Distribution to parties
( )Review&Comment ( )Record
(X)Use O Execution
The following:
(X)Other ( )Shop Drawing Prints
( )Specifications ( )Shop Drawing Reproducible
( )Bonds ( )Contract Documents
Copies Date Rev.No. Description
I Final Paperwork&Consent of Surety
REMARKS:
COPIES TO: (with enclosures)
( ) BY: Rob Taylor
6331 Southwest Blvd. /Benbrook,Texas 76132
817/735-1600 ext.316 Fax 817/735-1613
rob@gilcocontracting.com
CONSENT OF OWNER ❑
SURETY COMPANY ARCHITECT ❑
CONTRACTOR ❑
TO FINAL PAYMENT SURETY ❑
Conforms with the American Institute of OTHER
Architects,AIA Document G707
Bond No 022056842
PROJECT:
(name, address)Primrose Crossing Phase 4-Paving Improvements
Fort Worth TX
TO (Owner)
WILBOW-LLANO SPRINGS DEVELOPMENT ARCHITECT'S PROJECT NO:
CORPORATION CONTRACT FOR:
4131 N.Central Expressway,Suite 990 Primrose Crossing Phase 4-Paving Improvements
Dallas TX 75204 CONTRACT DATE:
CONTRACTOR:GILCO CONTRACTING, INC.
In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above,the
(here insert name and address of Surety Company)
LIBERTY MUTUAL INSURANCE COMPANY
175 Berkeley Street
Boston MA 02116 , SURETY COMPANY
on bond of (here insert name and address of Contractor)
GILCO CONTRACTING, INC.
6331 Southwest Boulevard
Benbrook TX 76132 , CONTRACTOR,
hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall not relieve
the Surety Company of any of its obligations to (here insert name and address of Owner)
WILBOW-LLANO SPRINGS DEVELOPMENT CORPORATION
4131 N.Central Expressway,Suite 990
Dallas TX 75204 , OWNER,
as set forth in the said Surety Company's bond.
IN WITNESS,WHEREOF,
the Surety Company has hereunto set its hand this 30th day of May, 2018
LIBERTY MUTUAL INSURANCE COMPANY
Sur Company
Attest:Tina McEwan JD" 4&niil)
(Seal): Signa re of Authorized Representative
Sophinie Hunter Attorney-in-FactHunter Attorney-in-Fact
Title
NOTE; This farm is to be used as a companion document to AIA DOCUMENT G706, CONTRACTOR'S AFFIDAVIT OF PAYMENT OF DEBTS AND CLAIMS,
Current Edition
ONE PAGE
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND.
This Power of Attorney limits the acts of those named herein,and they have no authority to bind the Company except in the manner and to the extent herein stated.
Certificate No.7988971
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company West American Insurance Company
POWER OF ATTORNEY
KNOWN ALL PERSONS BY THESE PRESENTS:That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire,that
Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts, and West American Insurance Company is a corporation duly
organized under the laws of the State of Indiana(herein collectively called the"Companies"),pursuant to and by authority herein set forth,does hereby name,constitute and appoint,
Robbi Morales;Don E.Cornell;Sophinie Hunter-,V.DeLene Marshall-,Tina McEwan•Ricardo J Reyna;Kelly A Westbrook
all of the city of Dallas state of Tx each individually if there be more than one named,its true and lawful attorney-in-fact to make,execute,seal,acknowledge
and deliver,for and on its behalf as surety and as its act and deed,any and all undertakings,bonds,recognizances and other surety obligations,in pursuance of these presents and shall
be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons.
IN WITNESS WHEREOF,this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed
thereto this 24th day of January 2018 a+
cc
`L('(INSUA VCJSU,,� tiV 1WSUr1, V
The Ohio Casualty Insurance Company 0
ot of o r 191 x y T 1991 ° Liberty Mutual Insurance Company d
' WestAmerican Insurance Company c
U) J�`''•nr: '` .L'-' �1�`rumh''•Ta `rr�nun , ��,./y./ ///� •/y�
CD
�
David M.Care Assistant SecretaryC c STATE OF PENNSYLVANIA ss Y �
COUNTY OF MONTGOMERY
O 3 On This 24th da of January 2018 O
L tM Y ,before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance u I.-
v N Company,The Ohio Casually Company,and West American Insurance Company,and that he,as such, being authorized so to do,execute the foregoing instrument for the purposes �,�
0.2 therein contained by signing on behalf of the corporations by himself as a duly authorized officer. O LV
M c
N?
Liberty
Mutual.
SURETY
TEXAS TEXAS
IMPORTANT NOTICE AVISO IMPORTANTE
To obtain information or make a complaint: Para obtener informacion o para someter una
queja:
You may call toll-free for information or to Usted puede hamar al humero de telefono gratis
make a complaint at para informacion o para someter una queja al
1-877-75I-2640 1-877-751-2640
You may also write to: Usted tambien puede escribir a:
2200 Renaissance Blvd., Ste, 400 2200 Renaissance Blvd., Ste. 400
King of Prussia,PA 1.9406-2755 King of Prussia, PA 19406-2755
You may contact the Texas Department of Puede comunicarse con el Departamento de
Insurance to obtain information on companies, Seguros de Texas para obtener informacion
coverages, rights or complaints at acerca de companias, coberturas, derechos o
1-800-252-3439 quejas al
1-800-252-3439
You may write the Texas Department of Insurance Puede escribir al Departamento de Seguros
Consumer Protection (I 11-1A) de Texas Consumer Protection (1I I-IA)
P. 0. Box 149091 P. 0. Box 149091
Austin, TX 78714-9091 Austin,TX 78714-9091
FAX: (512) 490-1007 FAX# (512) 490-1007
Web: littp://www.tdi.texas.gov Web: htt>a'//www tdi texas.gov
E-mail: Cons umerProtectionnatdi texas.aov E-mail: ConsumerProtection@tdi.texas. ov
PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS 0 RECLAMOS:
Should you have a dispute concerning your Si tiena una disputa concerniente a su prima o a
premium or about a claim you should first un reclamo, debe comunicarse con el agen
contact the agent or call 1-800-843-6446, primero. Si no se resuelve la disputa, puede
If the dispute is not resolved, you may contact the entonces comunicarse con el departamento (TDI)
Texas Department of Insurance.
ATTACH THIS NOTICE TO YOUR UNA ESTE AVISO A SU POLIZA:
POLICY: 11,
This notice is for information only and does not Este aviso es solo para proposito de informacion
become a part or condition of the attached y no se convierte en parte o condicion del
document. documento adjunto.
NP 70 68 09 01
LMS-15292 10115
AFFIDAVIT
STATE OF TEXAS
COUNTY OF TARRANT
Before me, the undersigned authority, a notary public in the state
and county aforesaid, on this day personally appeared Rob Taylor, Project
Coordinator of Gilco Contracting, Inc.,known to me to be a credible
person, who being by me duly sworn,upon his oath deposed and said;
That all persons, films, associations,corporations, or other
organizations furnishing labor and/or materials have been paid in full;
That the wage scale established by the City Council in the City of
Fort Worth has been paid in fiill;
That there are no claims pending for personal injury and/or
property damages;
On Contract described as;
Paving Improvements to serve: Primrose Crossing, Phase 4
BY: Rob Taylor
Subscribed and sworn before me on this 30th of Maw , 2018.
Notary`P;i�blic
Tarrant County,TX
otnar pia,, MARY PANNELL
Notaty PublIQ .1,tat&of T0X
',"•,Pj;:`.��c'C:drllrri,Expit�l?± iti-17-�pi�
°F NWMY ID 69442J9
May 30, 2018
City of Fort Worth
CFA Administration
1000 Throckmorton St.
Fort Worth,TX 76102
RE: Final Waiver of Lien; Paving Improvements to serve Primrose Crossing,Phase 4
City Project#100534
File No. W-2429
File No. X-23833
The purpose of this letter is to acknowledge that we have been paid in full by Wilbow
Development Corporation for the public improvements constructed to serve Primrose
Crossing,Phase 4 in Fort Worth,Texas. As a result, we hereby waive, release and
relinquish all rights to assert any claim or demand for lien in connection with this project.
Please feel free to contact me with any questions you may have.
Sincerely,
Rob Taylor
Project Coordinator
6331 Southwest Blvd.
Benbrook, Texas 76132
Office: 817.735.1600
Fax: 817.735.1613
GILCO CONTRACTING, INC.
TRANSMITTAL LETTER
PROJECT:Primrose Crossing,Phase 4
PROJECT NO.: 1209
DATE:May 30,2018
TO: City of Fort Worth
8851 Camp Bowie W.Blvd.
Fort Worth,Texas 76116
We transmit:
(X)Herewith ( )Under Separate cover via
For Your:
( )Approval ( }Distribution to parties
( )Review&Comment ( )Record
(X)Use ( )Execution
The following:
(X)Other ( )Shop Drawing Prints
( )Specifications ( )Shop Drawing Reproducible
( )Bonds ( )Contract Documents
Copies Date Rev.No. Description
I Final Paperwork&Consent of Surety
REMARKS:
COPIES TO: (with enclosures)
( ) BY: Rob Taylor
6331 Southwest Blvd. /Benbrook,Texas 76132
817/735-1600 ext.316 Fax 817/735-1613
rob@gilcocontracting.com
CONSENT OF OWNER ❑
SURETY COMPANY ARCHITECT ❑
CONTRACTOR ❑
TO FINAL PAYMENT SURETY ❑
Conforms with the American Institute of OTHER
Architects,AIA Document G707
Bond No 022056842
PROJECT:
(name, address)Primrose Crossing Phase 4-Paving Improvements
Fort Worth TX
TO (Owner)
WILBOW-LLANO SPRINGS DEVELOPMENT ARCHITECT'S PROJECT NO:
CORPORATION CONTRACT FOR:
4131 N.Central Expressway,Suite 990 Primrose Crossing Phase 4-Paving Improvements
Dallas TX 75204 —J CONTRACT DATE:
CONTRACTOR:GILCO CONTRACTING,INC.
In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above,the
(here insert name and address of Surety Company)
LIBERTY MUTUAL INSURANCE COMPANY
175 Berkeley Street
Boston MA 02116 , SURETY COMPANY
on bond of there insert name and address of Contractor)
GILCO CONTRACTING, INC.
6331 Southwest Boulevard
Benbrook TX 76132 , CONTRACTOR,
hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall not relieve
the Surety Company of any of its obligations to (here insert name and address of Owner)
WILBOW-LLANO SPRINGS DEVELOPMENT CORPORATION
4131 N.Central Expressway,Suite 990
Dallas TX 75204 , OWNER,
as set forth in the said Surety Company's bond.
IN WITNESS,WHEREOF,
the Surety Company has hereunto set its hand this 30th day of May,2018
LIBERTY MUTUAL INSURANCE COMPANY
SuleiyCompany
Attest:Tina McEwan j4" �Lio
(Seal): Signa re of Authorized Representative
Sophinie Hunter Attorney-in-Fact
Title
NOTE: This farm is to 5e used as a companion document to AIA DOCUMENT G706, CONTRACTOR'S AFFIDAVIT OF PAYMENT OF DEBTS AND CLAIMS,
Current Edition
ONE PAGE
I
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND.
This Power of Attorney limits the acts of those named herein,and they have no authority to bind the Company except in the manner and to the extent herein stated.
Certificate No.7988971
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company West American Insurance Company
POWER OF ATTORNEY
KNOWN ALL PERSONS BY THESE PRESENTS:That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire,that
Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts, and West American Insurance Company is a corporation duly
organized under the laws of the State of Indiana(herein collectively called the"Companies"),pursuant to and by authority herein set forth,does hereby name,constitute and appoint,
Robbi Morales;_Don E.Cornell;Sophinie Hunter,•V.DeLene Marshall:Tina McEwan•Ricardo J Reyna;Kelly A Westbrook
all of the city of Dallas state of TX each individually if there be more than one named,its true and lawful attorney-in-fact to make,execute,seal,acknowledge
and deliver,for and on its behalf as surety and as its act and deed,any and all undertakings,bonds,recognizances and other surety obligations,in pursuance of these presents and shall
be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons.
IN WITNESS WHEREOF,this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed
thereto this 24th day of January 2018 >,
ca
N (il P Iwsui r .,tasui,., "Q
r•"'" "�'- ;JcS' Aq<3��^ e".s""°' ;,''r. The Ohio Casualty Insurance Company N
l a>> g 19u T t 991 Liberty Mutual Insurance Company aNi
WestAmerican Insurance Company
(+ By: 4 ar J?
w 0 STATE OF PENNSYLVANIA ss David M.Carey,Assistant Secretary C
COUNTY OF MONTGOMERY
4? On this 24th day of January 2018,before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance v
w (D Company,The Ohio Casualty Company,and West American Insurance Company,and that he,as such, being authorized so to do,execute the foregoing instrument for the purposes >,u)
0.2 therein contained by signing on behalf of the corporations by himself as a duly authorized officer. d UJ
c
N > IN WITNESS WHEREOF,I have hereunto subscribed my name and affixed my notarial seal at King of Prussia,Pennsylvania,on the day and year first above written. O rL
d sr^ PAST P COMMONWEALTH OF PENNSYLVANIA
— A
Notarial Seal
Eu,,oT
a Paslella,Notary Public By: •�t�� _� 0
o d °F ionTwp.,Montgomery County Teresa Paslella,Notary Public yO �°�h Lv��3 ssion Expires March 28,2021 3
C.+� �grfi1' �G Member,Ptnnsylvani:,Association uF Nufurlvs fE6
13.
C ca This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual y o
y Insurance Company,and West American Insurance Company which resolutions are now in full force and effect reading as follows: =o
+.�
ca d ARTICLE IV–OFFICERS–Section 12.Power of Attorney.Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President,and subject 0 e
to such limitation as the Chairman or the President may prescribe,shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Corporation to make,execute,seal,
O c acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety obligations.Such attorneys-in-fact,subject to the limitations set forth in their respective 'a
E 1.�: powers of attorney,shall have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so m
r1 i executed,such instruments shall be as binding as if signed by the President and attested to by the Secretary.Any power or authority granted to any representative or attomey-in-fact under >'a
,a >� the provisions of this article may be revoked at any time by the Board,the Chairman,the President or by the officer or officers granting such power or authority. a,CD
0 = ARTICLE XIII–Execution of Contracts–SECTION 5.Surety Bonds and Undertakings.Any officer of the Company authorized for that purpose in writing by the chairman or the president, �.c?
m and subject to such limitations as the chairman or the president may prescribe,shall appoint such attorneys-in-fact.as may be necessary to act in behalf of the Company to make,execute, M
o seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety obligations. Such attorneys-in-fact subject to the limitations set forth in their =o?
Z respective powers of attorney,shall have full power to bind the Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so 00
executed such instruments shall be as binding as if signed by the president and attested by the secretary. U V–
Certificate of Designation–The President of the Company,acting pursuant to the Bylaws of the Company,authorizes David M.Carey,Assistant Secretary to appoint such attorneys-in- ~`–
fact as may be necessary to act on behalf of the Company to make,execute,seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety
obligations.
Authorization–By unanimous consent of the Company's Board of Directors,the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the
Company,wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds,shall be valid and binding upon the Company with
the same force and effect as though manually affixed.
I, Renee C. Llewellyn, the undersigned,Assistant Secretary, The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company do
hereby certify that the original power of attorney of which the foregoing is a full,true and coned copy of the Power of Attorney executed by said Companies,is in full force and effect and
has not been revoked.
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this day of _2011—
I
2011—.
� j���+
g :: 19iz ° �° tgyt T By: ,
ro
, �� ,,`, � � Renee C.Lle 1 ssistant Secretary 1
268 of 400
LMS 12873 022017
Liberty
Mutual
SURETY
TEXAS TEXAS
IMPORTANT NOTICE AVISO IMPORTANTE
To obtain information or make a complaint: Para obtener informacion o para someter una
queja:
You may call toll-free for information or to Usted puede llamar al numero de telefono gratis
make a complaint at para infonnacion o para someter una queja al
1-877-751-2640 1-877-751-2640
You may also write to: Usted tambien puede escribir a:
2200 Renaissance Blvd., Ste. 400 2200 Renaissance Blvd., Ste. 400
King of Prussia,PA 1.9406-2755 King of Prussia, PA 19406-2755
You may contact the Texas Department of Puede comunicarse con el Departamento de
Insurance to obtain information on companies, Seguros de Texas para obtener informacion
coverages, rights or complaints at acerca de companias, coberturas, derechos o
1-800-252-3439 quejas al
1-800-252-3439
You may write the Texas Department of Insurance Puede escribir aI Departamento de Seguros
Consumer Protection (111-1A) de Texas Consumer Protection (I I I-IA)
P. 0. Box 149091 P. 0. Box 149091
Austin, TX 78714-9091 Austin,TX 78714-9091
FAX: (512) 490-1007 FAX#(512)490-1007
Web: littp://www.tdi.texas.gov Web: http'//www tdi texas.gov
E-mail: ConsumerProtection@tdi.texas.gov E-mail: Cons umerProtectionna tdi.texas.gov
PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS 0 RECLAMOS:
Should you have a dispute concerning your Si tiena una disputa concerniente a su prima o a
premium or about a claim you should first un reclamo, debe comunicarse con el age te o
contact the agent or call 1-800-843-6446. primero. Si no se resuelve la disputa, puede
If the dispute is not resolved, you may contact the entonces comunicarse con el departamento (TDI)
Texas Department of Insurance.
ATTACH THIS NOTICE TO YOUR UNA ESTE AVISO A SU POLIZA:
POLICY:
This notice is for information only and does not Este aviso es solo para proposito de informacion
become a part or condition of the attached y no se convierte en parte o condicion del
document. documento adjunto.
M'70 68 09 01
LMS-15292 10115
AFFIDAVIT
STATE OF TEXAS
COUNTY OF TARRANT
Before me,the undersigned authority,a notary public in the state
and county aforesaid, on this day personally appeared Rob Taylor,Project
Coordinator of Gilco Contracting, Inc.,known to me to be a credible
person, who being by me duly sworn,upon his oath deposed and said;
That all persons, firms,associations,corporations, or other
organizations furnishing labor and/or materials have been paid in full;
That the wage scale established by the City Council in the City of
Fort Worth has been paid in Rill;
That there are no claims pending for personal injury and/or
property damages;
On Contract described as;
Paving Improvements to serve: Primrose Crossing,Phase 4
BY: Rob Taylor
Subscribed and sworn before me on this 30th of May ,2018.
Notarv�Public
Tarrant County,TX
MARY PANNELL
Notary Publlc�,-1016%of Texcafi
cN%f%v rr,`-�b11'll`ri,
Fik'� €xplr; � 1C+=1'�-2015
May 30,2018
City of Fort Worth
CFA Administration
1000 Throckmorton St.
Fort Worth,TX 76102
RE: Filial Waiver of Lien; Paving Improvements to serve Primrose Crossing,Phase 4
City Project 4100534
File No. W-2429
File No. X-23833
The purpose of this letter is to acknowledge that we have been paid in frill by Wilbow
Development Corporation for the public improvements constructed to serve Primrose
Crossing,Phase 4 in Fort Worth,Texas. As a result, we hereby waive,release and
relinquish all rights to assert any claim or demand for lien in connection with this project.
Please feel free to contact me with any questions you may have.
Sincerely,
' 7. 4
Rob Taylor
Project Coordinator
6331 Southwest Blvd.
Benbrook, Texas 76132
Office: 817.735.1600
Fax: 817.735.1613
Greensheet for Primrose
, __ Crossing Phase 4 CPN#100534
P
--- - -- Adobe Sign Document History 07/31/2018
- w Created: 07/20/2018
By: Shameka.Kennedy@fortworthtexas.gov
Status: Signed
Transaction ID: CBJCHBCAABAAW1bIJsUskIHViXxftw5GYv3RuJ4L8fm1
"Greensheet for Primrose Crossing Phase 4 CPN#100534 P" Hi
story
"D Document created by Shameka.Kennedy@fortworthtexas.gov
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E� Document emailed to Rob Taylor adt@gilcocontracting.com)for signature
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Document viewed by Rob Taylor Qdt@gilcocontracting.com)
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�i Rob Taylor odt@gilcocontracting.com) uploaded the following supporting documents:
G File Attachment 1
0 File Attachment 2
07/20/2018-10:46:34 AM CDT
CSc, Document e-signed by Rob Taylor Qdt@gilcocontracting.com)
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dc; Document e-signed by James Diver Qames.diver@fortworthtexas.gov)
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FORTWORTH.
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