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Contract 50014-FP1
FORTWORTH® RECEIVED CITY SECRETARY pp1q,01 8 2019 CONTRACT NO. MAY 2 TRANSPORTATION AND PUBLIC WORKS CnY"SM5""'M NOTICE OF PROJECT COMPLETION Cny SECRETARY City Project Ns: 100744,100747 Regarding contract 50014 for HMAC STREET REHAB AT MULTIPLE LOCATIONS (2017-4)as requited by the TRANSPORTATION& PUBLIC WORKS as approved by City Council on 10/24/2017 through M&C C-28446 the director of the TRANSPORTATION&PUBLIC WORKS upon the recommendation of the Assistant Director of the Transportation&Public Works Department has accepted the project as complete. Original Contract Prices: $501,676.45 Amount of Approved Change Orders: $82,621.00 Ns l > M Revised Contract Amount: \ = $584,297.45 Total Cost Work Completed: H _ _ $440,245.21 -qr� Q V �aE ' Less Deductions: y Q. >+ a� 71 m cn M c. c . J Liquidated Damages: H c > 0 Days @$210.00/Day c Ma oT— � � tom ` >, Pavement Deficiencies: Ca o5v :r Total Deduction Amount: a = m M 0. � o� a y- a� E y r 4) c Total Cost Work Completed: _ N = !La $440,245.21 Less Previous Payments: E — d Q $418,232.94 M �Y W 0- 0 M s Final Payment Due .C! ;ma U. V $22,012.26 Recommended for Acceptance Date �As�st. Director, TPW - Infrastructure Design and Construction 4Acced Date 4b Director, TRANSPORTATION & PUBLIC WORKS 9 n� 1z'- Asst. Ci Manager Date Comments: 3940t-f- ZOUMOO- 100-1-411- eeTAIN $15,I401 -3s 3 r14(u- lov0000- 10o--4-4- ftTA ItJ ` o I qp2-q I OFFICIAL.RECORD CITY SECRETARY FT.WORTH.TX TPW Scan �) y TPW Construction Invoice Contract: CS50014 P.O.# 18-102504 Payment Date: 4/29/2019 TO:JLB Contracting,LLC INV.# CS50014-10 f INA-L Estimate No. 10 DOE: P O Box 24131 ProjNlanager Kristian Sugrim Fort Worth TX 76124 FOR: HMAC 2017-4 Street Rehabilitation Contract Amount: $584,297.45 Completed Ret Pen Ad-j Pay Total to Date: $440,245.21 $0.00 $0.00 $0.00 $440,245.21 Previous Estimate: $440,245.21 $0.00 $0.00 $0.00 $418,232.95 Earned to Date: $0.00 ($22,012.26) $0.00 $0.00 $22,012.26 Payments: 39406-0200431-5740010-100744-002480 $383,731.00 Comments:CO#1:$82,621 Total to Date: $302,987.05 $0.00 $0.00 $0.00 $302,987.05 Previous Estimate: $302,987.05 $15,149.35 $0.00 $0.00 $287,837.70 Earned to Date: $0.00 ($15,149.35) $0.00 $0.00 $15,149.35 39406-0200131-5740010-100747-002480 $200,566.45 Total to Date: $137,258.16 $0.00 $0.00 $0.00 $137,258.16 Previous Estimate: $137,258.16 $6,862.91 $0.00 $0.00 $130,395.25 Earned to Date: $0.00 ($6,862.91) $0.00 $0.00 $6,862.91 'fran porta8„n K isut�:i,:�°>r.rt:� BUSINESS SUl'FOf�I 0':O; `P Contact Person.`Phrrer Nftitkr 1 ANDREA MUNOZ X 2312 Department Approval Signature(1'natc'l CAROL BUKOVIC X 8643 =Appital n re . Friday,May 3,2019 Page 1 of 1 Routing And Transmittal Slip Date 5/1/19 TO: Initials: Date: Itzel Alma uer I.A. 5/3/19 Kristian Su rim S 'S ,� Ri chardo Matute .��` « Steve Cooke 51 � *. - Susan Al ani s Nikki McLero >� <� Itzel Alma uer _ACTION _FILE _APPROVAL _FOR CLEARANCE _PER CONVERSATION AS REQUESTED _FOR CORRECTION _PREPARE REPLY _CIRCULATE _FOR YOUR INFORMATION _SEE ME _COMMENT _INVESTIGATE X SIGNATURE _COORDINATION _JUSTIFY _OTHER NOTE AND RETURN N' ' MUeroy 18363 Phone No. FORTWORTH® Account Inquiry Fiscal Year: 2019 YTD as of 09/30/2019 Period: 17 General Ledger ACTUALS Run Time: 04/24/2019 11:26 AM Report ID: GL0070 Export Ledger Data Export Journal Data Account Account Descrip!jon Fund �- • Amount Activity iReference 2060000 Retainage Payable 39406 100744 'RETAIN $0.00 ($15,149,35) 2060000 Retainage Payable 39406 100747 RETAIN $0,00 ($6.862.91Parameter Value Report ID GL0070 Fiscal Year 2019 Accounting Period 17 Ledger ACTUALS Fund Code 10100,13001,13002,19100,19907,19908,19909,19910,20101,20102,20103,20104,20105,20106,21001,21002,21003,23001,23002,25001,25002,25003,25004,25005,25006,25007,25008,25010,25011.25012,26001,26002,26003 ,26004,26005,26006,27001,28001,28002,28003,28004,28005,28006,28007,28008,28009,28010,28011,28501,28502,28503,28504,28505,28506,28507,28508,28510,28511,28512,28514,28515,28516,28517,28518,28519,2860 3,28604,28606,28607,28608,28609,28610,28612,28613,28614,28615,28710,28721,28722,28730,28770,28790,29001,29002,29500,30100,30101,30102,30103,30104,30105,30106,30107,30108,30109,30110,30111,30112,301 13,30200,30205,30206,31001,31002,31003,33001,33002,33003,33004,33005,34009,34010,34011,34012,34013,34014,34016,34017,34018,34019,35005,36001,36002,36003,36004,36005,36006,39001,39002,39003,39004,39 005,39006,39007,39008,39009,39100,39101,39102,39201,39209,39301,39302,39303,39304,39402,39403,39405,39406,39407,39408,39409,39410,39411,39412,39501,39801,39802,40100,40101,40102,40103,40104,52001,5 2002,52003,52004,52005,52006,53001,53002,53003,53004,53005,54001,54002,54003,54501,54502,54503,54504,55001,55002,55003,55004,55005,55006,56001,56002,56003,56004,56005,56006,56007,56008,56009,56010, 56011,56012,56013,56014,56015,56016,56501,56502,57002,57003,57004,57005,57006,58001,59101,59302,59304,59401,59451,59501,59502,59601,59602,59603,59604,59605,59607,59608,59651,59652,59653,59900,59901 ,60101,60102,60103,60104,60105,60106,60107,60108,60109,60110,60111,60201,60202,69106,69900,69901,69902,69903,71010,71050,90000 Account 2060000 Project ID 100744,100747 Department NVS FSCM 92 Production Page 1 of 1 C-620 Signature Page Contractor's Application for Payment Invoice No. 10-Final To(Owner) City of Fort Worth Invoicing Period(From-To): Invoice Date: 2/5/2018 to 10/31/2018 4/29/2018 P.O. PO-18-00102504 From(Contractor): Remit to(If Not Automatic Deposit): Number: JLB CONTRACTING LLC Project: 100744,100747 Contractor's CFW Vendor No.: 0000016042 City secretary ContNumber: b um Num 50014 contract HMAC STREET REHAB AT MULTIPLE LOCATIONS (2017-4) Nber: Name: Application For Payment Change Order Summary Approved Change Orders 1. ORIGINAL CONTRACT PRICE........................................................... $ $501,676.45 Number Additions Deletions 2. Net change by Change Orders................................................................. $ $82,621.00 1 $82,621.00 3. Current Contract Price(Line 1 f 2)........................................................ $ $584,297.45 2 4. TOTAL COMPLETED AND STORED TO DATE 3 (Progress Estimate,Construction Allowance and Change Orders)....... $ $440,245.21 4 5. RETAINAGE: 5 a. X $440,245.21 Work Completed.......... S 6 b. X Not Used $ 7 c.Total Retainage(Line 5a+Line 5b)................................ $ 8 6. AMOUNT ELIGIBLE TO DATE(Line 4-Line 5c)............................. $ $440,245.21 TOTALS $82,621.00 .....plic.................. ( P Application) $ $418,232.94 NET CHANGE BY S. AMOUNT DUE UTH S APPLICATION.from prior A lication......... $ $22,012.26 $82,621.00 CHANGE ORDERS 9.BALANCE TO FINISH,PLUS RETAINAGE (Column G on Progress Estimate+CA+COs+Line 5 above)............... $ $144,052.25 Contractor's Certification 10. CONTRACT TIME: The Contractor certifies with the submittal of this document and associated Payment Request Submittal a. Days Awarded 90 on the City of Fort Worth Buzzsaw system that to the best of their knowledge:(1)all previous progress b, Days Added by CO 30 payments received from Owner on account of Work done under the Contract have been applied on account to discharge Contractor's legitimate obligations incurred in connection with Work covered by C. Total Days 120 prior Applications for Payment;(2)title of all Work,materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to Owner at time of payment free and clear of all Liens,security interests and encumbrances(except such as are covered by d. Days Charged !10 5 a Bond acceptable to Owner indemnifying Owner against any such Liens,security interest or e, Days Remaining encumbrances);and(3)all Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. C�S ISO s. DMI46 f QtY ai ti 4 5 0 This document has been modified from its original form as an EJCDC document and the user did not highlight the modifications.You are encouraged to read the document carefully and consult Legal Counsel prior to its execution. C-620 Signature Page Contractor's Application for Payment Invoice No. 10-Final To(Owner) City of Fort Worth Invoicing Period(From-To): Invoice Date: 2/5/2018 to 10/31/2018 4/29/2019 P.0. PO-18-00102504 From(Contractor): Remit to(If Not Automatic Deposit): Number- JLB CONTRACTING LLC Project: 100744,100747 ContractorsCFW Vendor No.: 0000016042 City Secretary Contract 50014 Contract HMAC STREET REHAB AT MULTIPLE LOCATIONS (2017-4) Number- Name: Application For Payment Change Order Summary / Approved Change Orders 1. ORIGINAL CONTRACT PRICE........................................................... $ $501,676.45 /✓ Number Additions Deletions 2. Net change by Change Orders................................................................. $ $82,621.00 V 1 $82,621.00 3. Current Contract Price(Line 1 t 2)........................................................ $ $584,297.45 2 4. TOTAL COMPLETED AND STORED TO DATE 3 (Progress Estimate,Construction Allowance and Change Orders)....... $ $440,245.21 4 5. RETAINAGE: 5 a. X $440,245.21 Work Completed.......... $ 6 b. X Not Used $ 7 c. Total Retainage(Line 5a+Line 5b)................................ $ 8 6. AMOUNT ELIGIBLE TO DATE(Line 4-Line 5c)............................. $ $440,245.21 TOTALS $82,621.00 7. LESS PREVIOUS PAYMENTS(Line 6 from prior Application)......... $ $418,232.94 NET CHANGE BY $82,621.00 8• AMOUNT DUE THIS APPLICATION................................................. $ $22,012.26 CHANGE ORDERS 19.BALANCE TO FINISH,PLUS RETAINAGE (Column G on Progress Estimate+CA+COs+Line 5 above)............... $ $144,052.25 Contractor's Certification 10. CONTRACT TIME: / The Contractor certifies with the submittal of this document and associated Payment Request Submittal a. Days Awarded 90 on the City of Fort Worth Buzzsaw system that to the best of their knowledge:(1)all previous progress b, Days Added by CO 30 payments received from Owner on account of Work done under the Contract have been applied on ✓ account to discharge Contractor's legitimate obligations incurred in connection with Work covered by c. Total Days 120 prior Applications for Payment;(2)title of all Work,materials and equipment incorporated in said Work J or otherwise listed in or covered by this Application for Payment will pass to Owner at time of payment d Days Charged 120 free and clear of all Liens,security interests and encumbrances(except such as are covered by a Bond acceptable to Owner indemnifying Owner against any such Liens,security interest or encumbrances); e, Days Remaining and(3)all Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. Received By T/PW Project Support fuel Almaguer APR 2 9 2019 This document has been modified from its original form as an EJCDC document and the user did not highlight the modifications.You are encouraged to read the document carefully and consult Legal Counsel prior to its execution. City of Fort Worth Summary of Charges City Secretary Contract Num: 50014 HMAC STREET REHAB AT MULTIPLE LOCATIONS P.0.: PO-18-00102504 Project Number 100744,100747 2017-4 Application Period: 2/5/2018 to 10/31/2018 Application 10-Final Application Date: 4/29/2018 Number: Funding Identification(FID) Total Completed Amt Remaining Gross Retainage Net Totals 39406-0200431-5740010--100744-002480-- $296,022.17 $87,709.05 39406-0200431-5740010--100747-002480-- $144,223.04 $56,343.19 0 0 0 0 0 0 0 0 0 / Grand Total $440,245.21 $144,052.25 $0.00 $0.00 $22,012.26 ✓ 3gV0(P _ ZaCo000- lao� gL/- 0K"-7/ -0V 15, )y0, 3S 3�yojO- UtpeDoa — 1 DD--TqT - Vzt TA-f N (.0 1 9(0. 11 City of Fort Worth Summary of Charges City Secretary Contract Num: 50014 HMAC STREET REHAB AT MULTIPLE LOCATIONS P. PO-18-00102504 2017-4 project Number: 100744,100747 Application Period: 2/5/2018 to 10/31/2018 Application 10-Final Application Date: 4/29/2018 Number: Funding Identification(FID) Total Completed Amt Remaining Gross Retainage Net Original Contract 39406-0200431-5740010--100744-002480-- $233,240.83 $67,869.39 39406-0200431-5740010--100747-002480-- $144,223.04 $56,343.19 0 0 0 0 0 0 0 0 0 Change Order 1 39406-0200431-5740010--100744-002480-- $62,781.33 $19,839.67 39406-0200431-5740010--100747-002480-- 0 0 0 0 0 0 0 0 0 Change Order 2 39406-0200431-5740010--100744-002480-- 39406-0200431-5740010--100747-002480-- 0 0 0 0 0 0 0 0 0 City of Fort Worth Summary of Charges PEE Number: Contract Num: 50014 HMAC STREET REHAB AT MULTIPLE LOCATIONS P.0.: PO-18-00102504 Project Number: 100744,100747 2017-4 Application Period: 2/5/2018 to 10/31/2018 Application 10-Final Application Date: 4/29/2018 Funding Identification(FID) Total Completed Amt Remaining Gross Retainage Net Change Order 3 39406-0200431-5740010--100744-002480-- 39406-0200431-5740010--100747-002480-- 0 0 0 0 0 0 0 0 0 Change Order 4 39406-0200431-5740010--100744-002480-- 39406-0200431-5740010--100747-002480-- 0 0 0 0 0 0 0 0 0 Change Order 5 39406-0200431-5740010--100744-002480-- 39406-0200431-5740010--100747-002480-- 0 0 0 0 0 0 0 0 0 City of Fort Worth Summary of Charges City Secretary Contract Num: 50014 HMAC STREET REHAB AT MULTIPLE LOCATIONS P. PO-18-00102504 Project Number: 100744,100747 2017-4 Application Period: 2/5/2018 to 10/31/2018 Ap umbe r:on Numbe 10-Final Application Date: 4/29/2018 Funding Identification(FID) Total Completed Amt Remaining Gross Retainage Net Change Order 6 39406-0200431-5740010--100744-002480-- 39406-0200431-5740010--100747-002480-- 0 0 0 0 0 0 0 0 0 Change Order 7 39406-0200431-5740010--100744-002480-- 39406-0200431-5740010--100747-002480-- 0 0 0 0 0 0 0 0 0 Change Order 8 39406-0200431-5740010--100744-002480-- 39406-0200431-5740010--100747-002480-- 0 0 0 0 0 0 0 0 0 C-620 Unit Pro,Progress Estimate Progress Estimate rem;�� 50014 Contractor's Application CivoFor1-1a°) HMAC STREET REHAB AT MULTIPLE LOCATIONS(2017-4) Apphum..Nlmh`r 10-Final Apptieatro.Pa..d 2/5/2018 to 10/31/2018 .4pp1"a°nn Date 4/29/2018 A B c n E F c Imp Tntel C.,1oled oo Balance to Fmnh Cnuriated Quanmy Mate�NPrexndy Did Item N. D.�cnpum, Spenfcabon Unaof Measure OrdQuanaty Una Pnce Bid value VA-Value Previously lnaelled Value Value llua Penod Stored m_.Cl and Stor Iu Date (1) IB-FI Senior No ID+E B 100744 PATE DRIVE 1 3305.0108 Miscellaneous Adjustment,(Utilaies) LS 1 WOOOD $3,601.25 $3,601 25 $3.601 25 2 02411300 Remove Concrete Curb&Gutter LF 540187200 $535 $289000 1277.650000D0 $6 835 48 w83548 E6,83548 2365% -$3.94548 3 321601M T'Concrete Curb&18"Gudar LF NO 228800 $23SO $1577947 1154400000DO $27,59016 $27.59016 $27.SW 16 1748% -$11.81069 4 02410401 Remove Concrete Dnvewav SF 498172640 $120 $59781 64225ODDODO $77070 $77070 $77070 1289% -$17289 5 32130Q F Concrete Dmoseav SF 1158401440 $590 SUM 57 64225CODDOO S3.78928 $3.78928 $3.78928 554% $3,04529 6 02410100 Remove Sidewalk SF 516178880 $110 $567.80 166330000000 $1.82963 $182963 $1.8M 63 3M 2% -$1.26183 7 321303114'Concrete Sldawelk SF 7202495M S475 $34.21186 2017.500WOOD $958313 $9.58313 $9,58313 280% $2462873 8 0241.1400 Remove Concrete Valley Gutter SV 60020800 $1025 $61521 $61521 9 321603027 Concrete Valle,Gutter SV 600208W $6260 $3,757W $3,75730 10 '241 0300 Renwve ADA Ramp EA 7 202496 $119 SO MW 70 6 WOWM0 $717 DO $717 DO $717 DO 83 3% $143 70 11 W W 9999 W ADA Ram. EA 144OQ92 $1,02000 $14.69309 18000000 $18.360DO $1836000 $18,36000 1250% 33.66591 12 NI)9 DOW Remove and Replace S Curb Inlet Too EA 1 200416 $4,125 DO _$4,951 72 $4,951.72 13 9999 WOO Remove and Replace 10 Curb Inlet To. EA 1 21%1416 $4.75 M $5731 99 $5.731 99 14 99990000 Remove and Replace 20'Curb Inlet Too EA 0600208 S868500 $5,21281 $521281 15 D24117M 10'Pavement Pulvaraabon SV 840891 Qw $455 $38.26056 787200000000 $35,81760 $35,817SO $35.817SO 936% $2,44296 16 3212 OD3027 Asi Pavement Tne D Sy 8408914080 $11M $94,34802 7872 OOOOOOOD $88,32384 $88,323M S88.32384 936% $6.02418 17 3211060D Cement Modification.131bsrsv TN 54618928 $135W $7.37356 5102W00DO $6,88770 $6.88770 $6.88770 934% $48586 18 999900M RoadBond ENI GA 66022880 E1M60 $7.17008 620000W00 $6.73320 $6,733.20 $6,73320 939% S43688 19 31240101 ASOhalt Pavement Base Rwair CV SO MONO $27860 $1672139 $16,72179 20 31230101 Unclassified Street Excavation CV 60020600 W35 $2,9620 2500M0000 $1.M375 $123335 $1,23375 417% S1,72828 21 3441 1301 Traffic LDDD Detector Cable Saw-Cut LF 69023920 $2715 $1,874 W $1,874 M M 34411M2 AWG Loo.Detector Cable LF 690239M $1630 $7,'25(W 5$12509 23 13010111 Water Valve Box A0lustments(w/Steal Riser) EA 2400832 $12600 S30250 S302.50 24 11.1.112 Water Valve Box Adiustments(w/Concrete Collar) EA 4 801664 $3M W $1 901 46 700000000 $2.772 W $2 TT2 GO $2 772 DO145 8% -$870 54 25 33M 0112 Me We Adlustment(w/Concrete Collar) EA 300 040 S65170 $1,95578 $1,95578 26 M1701W Curb Address Pamtmo EA 6W20M $4015 $24098 $24098 27 329201 W Bbck Sod Replacement SY 5401872W S570 $3,0791 81000000000 $4.61700 $4.61700 $4.617W IQ 9% -$1,53713 28 S999.M96 Pavina Construction Allonsnce LS 7 WOOOD 823489]4 $23,48974 $23,4&974 1 M747 ANDREW AVENUE _ 1 33050108 MIscellanem Adjustments(Ubhties) LS 1 WWW $2,3987: $2.39875 $2,39875 2 02411300 Remove Concrete Curb&Gutter LF 359812NO $635 $1925.M 45250ODW00 $2.42088 $2.42088 $2.42088 1258% -$49588 3 024, 02 T'Concrete Curb&lFGuOer LF 4397712M $23.90 $10,51053 452.50WOODD $10.8147: $10,81475 $10,81475 1029% -830422 4 02410401 Re move Concrete Drry v SF 331827360 $120 $39819 266280000000 $3.19536 $3/9536 $3.1W 36 8025% -$2.797A7 5 321304076"Concrete Dnvawev SF 7 598580 $590 USS243 2M2800MW0 $15,71052 $15.71052 815.71052 M51% ,11.15809 6 024101 W Remove Sidewalk SF 343821120 $110 $37820 239330000000 $263263 $2.63263 $2.63263 6961% $225443 7 32130311 V'Concrete Srdevalk SF 4797504000 $475 $22.78814 239330OWW0 $11,36818 Si1.368.18 $11.36818 499% $11,41997 8 02411400 Re move Concrete Vallev Gutter SV 399792M $1025 $40979 $40979 9 321603027'Concrete Vallev Gutter SV 39979200 $6260 $2,50270 $2,50270 10 02410300 Re.-ADA Ram. EA 4797504 $119.50 $57330 $57330 11 WW 0000 ADA Ram. EA 9595008 $1.02000 $9.78691 $9.78691 12 99.DOW Re move and RW...5'Curb Inlet TOD EA 0799584 $4125W $3.29821 $329828 13 9999 W W Remove and Replace 10'Curb Inlet Too EA 0799584 S4.775 00 $3.818 01 S3.818 01 14 9999 0.,Remove and Replace 20 Curb Inlet Top EA 0 3%792 $8.685 W $3 472.19 $3.47219 15 024117M 10'Pavemeta Pulveruabon SY 5601085920 1455 $25.48494 4795 WWWW $21817.25 $21,81725 $21.1111 856% $3.657.69 i6 3212003027 AsphaO Pavement T,ce D SV S601.M5920 $1122 $62.84418 47950WW000 $53.79990 S53.79SW $53.79990 856% 89.134428 17 3211 MOO Cement Modiflcabon.13 lbsrsv TN 36 W1072 $in00 $4 Oil*1 315400000D $4.257 GO $4257W $4,25790 857% $65354 18 9999.WW RcedBond ENi GA 43977120 $10860 $4.7)512 38 MMWW $4,12680 $4.12880 $4.12680 864% $64912 19 31240101 ASDhaft Pavement Base Reoair CV So 9792W $278SO $11.1382, $11.1W 21 20 31230101 Unclassified Street Excavation CY 39979200 $4935 81.97297 $1.97297 21 3441 1 W1 Tro(fe Loop Detector Cable Saw-Cut LF 45 976080 $27 15 E7 248.25 81.248 25 22 34411302 AWG Lw Detector Cable LF 45976080 $163. $74941 $74941 23 33M 0111 Wafer Valve Box Adiustments(wl Steel Riser) EA 7 5991M $126 M $201 50 $201 SO 24 3305 0112 Water Valve Box Adiustments Iwl Concrete Collar) EA 3198336 $3M OO $1.266 54 2 00000000 $792 W $792 M $792 M 62 5% $474 54 25 33050112 Manhole AdiustmaM(w/Concrete Collar) EA 1.998M0 $65170 $1,30272 $$30272 26 3217 DIM Curb Address Paintma EA 3997920 $4015 $16052 $16052 27 329201M Block Sort Replacement SV 3598128M $570 $2,OW 93 3M MOOD000 $1.710M S1.710M $1.710OD 834% S34093 28 9999 DOES Peonc Construction Allowance LS 1 WWOB $15,64628 $i5.64626 E15.64626 Totals $601.676A61 $348.606.021 $3U.506.62i $346606.62 695% 163169.83 Tius dmmt has been modified from as Dogma[f m,as an EJCDC d-unuct ant die user did nut highlIgnt the modi6catr"m Y.are enwuraWd tread Ibx d"cummt-filly and mnsuIt Ugal Cw )poor to itse 1h.. C-620 Change Order Progress Estimate Construction Allowance Usage Contractor's Application ADDITIONS For(coatmct> HMAC STREET REHAB AT MULTIPLE LOCATIONS(2017-4) Cdv secretary q heation Number 0744,1007 Contmctxnm 50014 PP ]0-Final Applwartion Period 2/5/2018 to 10/31/2018 Application Date 4/29/2018 A B C D E F than Total Completed a„ Balance to I-,It Estimated Quantdv Prevmusly Value Thro Materials PresenLLy Spenficahon Unit of Quantity to Add Unit Price Adddion Value Value and Stored b,Date (F) (B Item Number Description Section No Measure Installed Installed Value Period Stored(nntmC) (D+E B 30 Remove Tree, EA 300000000 $1,500 00 $4,500 00 300000000 $4,500 00 $4,500 00 $4,500 00 100 0% 31 Variable Height 0-12"Sidewalk Curb LF 35000000000 $2500 SUM 00 51685000000 $1292125 $1292125 $12,92125 1477% 44,17125 32 Remove&Replace Ramps(speeoil) EA 400000000 $1,675 00 $6300 00 4 00000000 $6,700 00 $3,350 00 $6,700 00 100 0% 33 Remove&Replace Valley Griper SY 100 00000000 $120 00 $12A00 00 40 30000000 $4,836 00 $4,836,00 $4,836 0. 40 3% $7,164 00 Totals S31,950.001 $28,957.251 $25,607,251 $28 957.25 90 6% $2 992.75 11 document has been modified from it,anginal fnmi as an EICDC document and the over did not highlight the mwlifiealions Yon are encouraged to read the daen i t carefully and consult Legal Counsel poor in it,e,ecution C-620 Change Order Progress Estimate Construction Allowance Usage Contractor's Application CONSTRUCTION ALLOWANCE ITEMS TO BE REDUCED For(contract) 0744,1007"MAC STREET REHAB AT MULTIPLE LOCATIONS(2017-4) Application Norther 10-Final Appbcation Penud 2/5/2018 to 10/31/2018 Appl—to,.Dar, 4/29/2018 A B C D E F Item Brd Item Number D—phon Specrfrcatron Uat of Quanhty m Delete Una Pnce Redaction Value Not Used Not Used Not Uxed Not Used Not Used Not Used Not Used Not Usat Section No Measure CONSTRUCTION A110WANCE LS 1.00000000 $31,95000 $31,95000 Totals $31 950.00 Tlas do-ramt has hem modified from its tngmal fomr as an EJCDC document and the user did not hrghhght the modifications Ynr arc encmnaged to read the docmnent carefully and,malt Legal Counsel pnor to its a<ectbon C-620 Change Order Progress Estimate Change Order Number 1 Contractor's Application ADDITIONS For(wormer) 0744,10W HMAC STREET REHAB AT MULTIPLE LOCATIONS(2017-4) City Secretary 50014 Apphcatmn Number 10-Final Contract Num Application Period 2/5/2018 to 10/31/2018 Application Date 4/29/2018 A B C D E F Item Addmon Total Completed / Balance to Fmrsh Change Order Item Specification Unit of Quan A y Change Estimated Quantity Pieviously Value This Materials Presently D—uphou CO tl to Add lJnrt Price ChaVal Order Installed Value Inaurded Value Period Stnred(not m C) and Stored to (B1 (B-F) No Section No Measure ) 29 COMBINATION SIDEWALK SF 10730000000t10 $770 $82,62100 815342000000 $62,78133 $62,79133 $62,78133 760 $19,83967 Totals $82 621A0 $62 781.33 $62 781.33 $62,781.331 76 0"o $19 839.67 Tlus dwument has been modified from its original tone as an EJCDC doeu ent and the user did not highlight the - modifications You are encouraged to read the doen—m carefully and consult Legal Counsel prior wit,ex—ition C-620 Change Order Progress Estimate Change Order Number 1 Contractor's Application DELETIONS For tmnhan) 0744,10W HMAC STREET REHAB AT MULTIPLE LOCATIONS(2017-4) Apphcatmn Number 10-Final Applrcahon Period 2/5/2018 to 10/31/2018 Appl—tor Date 4/29/2018 A B C D E F Item CO Quanhly to Deletion Change Order hem Specrfieitron unit of Unit Price Change Order Not Used Nnt lJsed Not Used Not Used Not Used Not Used Not Used Not U,ed No Description Section No Measure Delete Value Totals this document has been—hfied from its original form os on EJCDC document and the riser did not highlight the modifications Yon are encmireged to read the document carefull}and consult Legal Counsel prior to it,execution g AUTODESK'BIM 360' fortworthgov>100744-Pate Drive(Coleman to Berry)- A IA Document Management FOLDERS REVIEWS TRANSMITTALS ISSUES Reviews > Review detail OPEN #4-Final Review 0 Time left:3days FINAL-Construction Invoice Approval Workflow Start review Void entire review Name^ Version Markup Comments PROGRESS Copy of Copy of CPN 10 0 744-10 0747 Pate Andrew C-620 Contract... VS 0 No comments yet. Initiator Initial Review q Copy of Copy of CPN 10 0 744-10 0747 Pate Andrew C-620 Contract... VS 0 No comments yet. KS Kristian Sugrim May 21,4:15 PM < Copy of CPN 10 0 744-10 0747 Pate Andrew C-620 Contractor-s Um... VS 0 No comments yet. kristian.sugrim@fortworthtexas.gov> Submitted to Reviewer 1 Ci Copy of CPN 10 0 744-10 0747 Pate Andrew C-620 Contractor-s Unt... VS 0 No comments yet. Reviewer 1 Initial Review 1 n Ak Edwin Rodriguez May 22,7:11 AM <edwin.rod rig uez@fortworthtexas.gov> Submitted to Reviewer 2 OK Reviewer2 Initial Review 2 KS Kristian Sug rim May 22,10:11 AM <knsoan.sugnm@fortworthtexas.gov> Submitted to Reviewer 3 Reviewer3 Initial Review3 n LZ Lane Zarate May 22,10:36 AM <la ne.za rate@fortworthtexas.g ov> Submitted to Reviewer 4 approved Reviewer4 Initial Review 4 n JK Joanne Kamman May 24,3:55 PM <7oan ne.kamman @fortworthtexas.gov> Submitted to Approver Make sure calendar days are corrected on final scanned copy to address the additional 30 days in change orders Approver Final Review n Tpw Bsap Recon Team Send email notification BIM 360 Document Management Page 1 of 2 B, AUTODESK" BIM 360` fortworthgov > 100744-Pate Drive(Coleman to Berry) - A TR =� Document Management FOLDERS REVIEWS TRANSMITTALS ISSUES Reviews > Review detail OPEN #1 - Final Review CD Time left: 5 days pay estimate 10 submittal Start review Name Version PROGRESS Copy of CPN 10 0744-10 0747 Pate Andrew C-620 Contractor-s Unit Price Applicatio.._.pdf V1 Initiator SD Sam Davis Apr 29,2:22 PM p Copy of CPN 100744-100747 Pate Andrew C-620 Contractor-s Unit Price Applicatio.._.xtsm V1 Submitted to Reviewer 1 Reviewer 1 Initial Review 1 Edwin Rodriguez Apr 29,3:51 PM Submitted to Reviewer 2 Good. Reviewer2 Initial Review 2 KS Kristian Sugrim Apr 29,4:31 PM Submitted to Approver Approver Final Review Tpw Bsap Recon Team Send email notification https:Hdocs.b360.autodesk.com/projects/63d9al e4-3922-45b4-bc24-07fc4da4aca8/reviews/ecac2b 1 c-4e7a-45cb-889a-9Of564572... 5/1/2019 FORTWORTH rev 03/05/07 TRANSPORTATION & PUBLIC WORKS FINAL STATEMENT OF CONTRACT TIME FINAL STATEMENT NO.:10-FINAL NAME OF PROJECT: HMAC 2017-4 Street Rehab on Pate Dr.and Andrew Ave. PROJECT NO.: 100744/100747 CONTRACTOR: JLB Contracting,LLC DOE NO.: N/A PERIOD FROM:02/05/18 TO: 02/21/19 FINAL INSPECTION DATE: 21-Feb-19 WORK ORDER EFFECTIVE:N/A CONTRACT TIME: 120 Q WD O CD DAY OF DAYS REASON FOR DAYS DAY OF DAYS REASON FOR DAYS MONTH CHARGED CREDITED MONTH CHARGED CREDITED DURING DURING 1. 16. 2. 17. 3. 18. 4. 19. 5. 20. 6. 21. 7. 22. 8. 23. 9. 24. 10. 25. 11. 26. 12. 27. 13. 28. 14. 29. 15. 30. 31. SAT,SUN, RAIN,TOO WET, UTILITIES DAYS TOTAL &HOLIDAYS &TOO COLD RELOCATIONS OTHERS CHARGED DAYS THIS PERIOD 120 120 PREVIOUS PERIOD TOTALS TO DATE 120 120 *REMARKS: CONTRACTOR DATE INSPECXIOR DATE ENGINEERING DEPARTMENT The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX 76012-6311 (817)392-7941 •Fax: (817)392-7845 CONSENT OF OWNER ❑ SURETY COMPANY ARCHITECT ❑ CONTRACTOR ❑ TO FINAL PAYMENT SURETY ❑ OTHER (SIMILAR TO AIA DOCUMENT G707) Bond No. 8368032 PROJECT: HMAC 2017-4 Street Rehabilitation (name,address)Fort Worth, Texas TO (Owner) ARCHITECT'S PROJECT NO: City of Fort Worth CONTRACT FOR: Above Project 200 Texas Street Fort Worth, Texas 76102 CONTRACT DATE: October 24, 2017 CONTRACTOR: JLB Contracting, LLC 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) Westfield Insurance Company 555 Republic Drive, Suite 450 Plano, Texas 75074 ,SURETY COMPANY, on bond of(here insert name and address of Contractor) JLB Contracting, LLC P.O. Box 24131 ,CONTRACTOR, Fort Worth, Texas 76124 hereby approves of the final payment to the Contractor, and agrees that the final payment to the Contractor shall not relieve the Surety Company of any of its obligations to(here insert name and address of Owner) City of Fort Worth 200 Texas Street OWNER, Fort Worth, Texas 76102 , as set forth in the said Surety Company's bond. IN WITNESS WHEREOF, The Surety Company has hereunto set its hand this 18th day of December 2018 WESTFIELD INSURANCE COMPANY Surety C By 7/'r,,,, Si a e Authorized Representative Attest: (Seal): Kyle W. Sweeney Attorney—in—Fact Title Note:This form is intended to be used as a companion document to the Contractor's Affidavit of Payment of Debts and Claims,Current Edition THIS POWER OF ATTORNEY SUPERCEDES ANY PREVIOUS POWER BEARINU 1 HIJ JAMt .POWER#AND ISSUED PRIOR TO 04120111, FOR ANY PERSON OR PERSONS NAMED BELOW. POWER NO. 4220052 06 General Westfield Insurance Co. Power of Attorney Westfield National Insurance Co. Ohio Farmers Insurance Co. CERTIFIED COPY Westfield Center, Ohio Know All Men by These Presents, That WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY, corporations, hereinafter referred to individually as a -Company- and collectively as 'Companies," duly organized and existing under the laws of the State of Ohio, and having its principal office in Westfield Center, Medina County, Ohio, do by these presents make, constitute and appoint CHARLES D. SWEENEY, MICHAEL A. SWEENEY, KYLE W. SWEENEY, ELIZABETH GRAY, JOINTLY OR SEVERALLY of FORT WORTH and State of TX its true and lawful Attorney(s)-In-Fact, with full power and authority hereby conferred in its name, place and stead, to execute, acknowledge and deliver any and all bonds, recognizances, undertakings, or other instruments or contracts of suretyship- - - - - - - - -- - - - - - - - - - - - - - - - - - - - LIMITATION: THIS POWER OF ATTORNEY CANNOT BE USED TO EXECUTE NOTE GUARANTEE, MORTGAGE DEFICIENCY, MORTGAGE GUARANTEE, OR BANK DEPOSITORY BONDS. and to bind any of the Companies thereby as fully and to the same extent as if such bonds were signed by the President,sealed with the corporate seal of the applicable Company and duly attested by its Secretary, hereby ratifying and confirming all that the said Attorney(s)-in-Fact may do in the premises. Said appointment is made under and by authority of the following resolution adopted by the Board of Directors of each of the WESTFIELD INSURANCE COMPANY,WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY: 'Be It Resolved,that the President, any Senior Executive, any Secretary or any Fidelity& Surety Operations Executive or other Executive shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attorney(s)-in-Fact to represent and act for and on behalf of the Company subject to the following provisions: The Attorney-in-Fact. may be given full power and authority for and in the name of and on behalf of the Company,to execute,acknowledge and deliver, any and all bonds, recognizances, contracts, agreements of indemnity and other conditional or obligatory undertakings and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attorney-in-Fact shall be as binding upon the Company as if signed by the President and sealed and attested by the Corporate Secretary.- 'Se it Further Resolved,that the signature of any such designated person and the seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signatures or facsimile seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it is attached.' (Each adopted at a meeting held on February 8,2000). In Witness Whereof, WESTFIELD INSURANCE COMPANY, WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY have caused these presents to be signed by their Senior Executive and their corporate seals to be hereto affixed this 20th day of APRIL A.D.,2011 . �^ ti WESTFIELD INSURANCE COMPANY Corporate r.'•�SYR.(k"', �\0 At r' �IllsV Seals Q`•.. �`�o' ;'�?.• ""' •�SG:; ..... a WESTFIELD NATIONAL INSURANCE COMPANY •-. Affixedw; .a. :i� =O: '-,y =��:' OHIO FARMERS INSURANCE COMPANY SEAL _= By: State of Ohio "'„" """""""',• Richard L. Kinnaird, Jr., National Surety Leader and County of Medina ss.: Senior Executive On this 20th day of APRIL A.D.,2011 , before me personally came Richard L. Kinnaird, Jr. to me known, who, being by me duly sworn, did depose and say,that he resides-in Medina, Ohio;that he is Senior Executive of WESTFIELD INSURANCE COMPANY,WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY, the companies described in and which executed the above instrument;that he knows the seals of said Companies;that the seals affixed to said instrument are such corporate seals;that they were so affixed by order of the Boards of Directors of said Companies;and that he signed his name thereto by like order. Notarial 0,A-"1% Seal A%Al- S•, ' Affixed 'gyp William J. Kahelin,A rney at Law, Notary Public State of Ohio S 0d do My Commission Does Not Expire (Sec. 147.03 Ohio Revised Code) County of Medina ss.: 1, Frank A.Carrino, Secretary of WESTFIELD INSURANCE COMPANY,WESTFIELD NATIONAL INSURANCE COMPANY and OHIO FARMERS INSURANCE COMPANY, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by said Companies,which is still in full force and effect; and furthermore,the resolutions of the Boards of Directors,set out in the Power of Attorney are in full force and effect. In Witness Whereof, I have hereunto set my hand and affixed the seals of said Companies at Westfield Center, Ohio, this 18th day of Decembe, A.D. 2018 .�....,,..... yR•`aStIR.� C%s P\\ONA( LA �N•., •..Cis'••tip: �- •'y `4,'SEAL SEAL / t secret N, , 'o' =.=.18419!ae Frank A. Carrino, Secretary BPOAC2 (combined) (06-02) ' tl r , r AFFIDAVIT STATE OF TEXAS COUNTY OFTARRANT Before me, the undersigned authority, a notary public in the state and county aforesaid, on this day personally appeared Sam Davis, President of JLB Contracting, LLC, 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 full; That there are no claims pending for personal injury and/or property damages; On Contract described as; HMAC Street Rehabilitation 2017-4 - City Project# 100744, 100747 BY Sam Davis President JLB Contracting, LLC Subscribed and sworn before me on this day of Iri , 2019. *OU IC AND FO OUNTY, TEXAS My commission expires JAMIE GREENWAY d `© Notary Public, State of Texas 'i 'y *P Comm. Expires 09-25-2020 Notary ID 1211545-4