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Contract 57093-FP1
FORT WORTH, TRANSPORTATION AND PUBLIC WORKS NOTICE OF PROJECT COM LETION -FP1 City Secretary No: 57093 Date Received: 01/09/2024 City Project Ns: 102403 Regarding contract 57093 Daggett & McRae SRTS Improvements for as required by the TRANSPORTATION AND PUBLIC WORKS DEPARTM as approved by City Council on 12/14/2021 through M&C 21-0973 the director of the TRANSPORTATION AND PUBLIC WORKS DEPARTM upon the recommendation of the Assistant Director of the Transportation & Public Works Department has accepted the project as complete. Original Contract Amount: Amount of Approved Change Orders: Revised Contract Amount: Total Cost Work Completed: Less Deductions: Liquidated Damages: Pavement Deficiencies: Total Deduction Amount: Total Cost Work Completed: Less Previous Payments: Final Payment Due Patricia L. Wadsack (Jan 9, 202413:57 CST) Recommended for Acceptance Asst. Director, TPW - Capital Delivery $1,531,606.40 Days 240 $ 777.41 Ns 61 Days Added by CO 0 $ 1,532,383.81 Total Days 240 $ 1,483,850.09 Days Charged 301 61 Days @ $ 1,000 / Day $ (61,000.00) $ 1,483,850.09 $ 1,409,657.58 $ 13,192.51 Lauren Prieur (Jan 9, 202413:59 CST) Accepted Director, TRANSPORTATION AND PUBLIC WORKS DEPARTMENT William Johnson U n 9, 202414:01 CST) Asst. City Manager Comm nts: Jan 9, 2024 Date Jan 9, 2024 Date Jan 9, 2024 Date OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX C-620 Signature Page To (Owner) P. O. Number: Project: Contractor's Application for Payment City of Fort Worth Invoicing Period (From -To): '^nc FW020-0000007324 102403 From (Contractor): Urban Infraconstruction Contractor's CFW Vendor No.: 0000039969 City Secretary Contract 57093 Contract Number: Name: Application For Payment Change Order Summary (Approved Change Orders Number Additions 1 $777.41 2 3 4 5 6 7 8 TOTALS $777.41 NET CHANGE BY $777.41 CHANGE ORDERS Contractor's Certification Invoice No. 19 Final Invoice Date: 12/5/2023 Remit to ( If Not Automatic Deposit): Daggett and D. McRae SRTS Improvements 1. ORIGINAL CONTRACT PRICE.......................................................... $ $1,531,606.40 Deletions 2. Net change by Change Orders................................................................ $ $777.41 3. Current Contract Price (Line 1 f 2)....................................................... $ $1,5329383.81 4. TOTAL COMPLETED AND STORED TO DATE (Progress Estimate, Construction Allowance and Change Orders)......, $ $194839850.09 5. RETAINAGE: a. X $1,483,850.09 Work Completed........., $ b. X Not Used $ c. Total Retainage (Line 5a + Line 5b) ............................... $ 6. AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5c)............................ $ $1,483,850.09 7. LESS PREVIOUS PAYMENTS (Line 6 from prior Application)........ $ $194099657.58 8. AMOUNT DUE THIS APPLICATION ................................................ $ $74,192.51 9. BALANCE TO FINISH, PLUS RETAINAGE (Column G on Progress Estimate+ CA + Cos + Line 5 above) .............. $ $48,533.72 The Contractor certifies with the submittal of this document and associated Payment Request Submittal on the City of Fort Worth Buzzsaw system that to the best of their knowledge: (1) all previous progress 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 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 a Bond acceptable to Owner indemnifying Owner against any such Liens, security interest or encumbrances); and (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. Liquidated Damages $1,000.00 x day ,4n, Iq Tarnrr Mr Anup Tamrakar (Jan 2, 202411:12 CST) 10. CONTRACT TIME: a, Days Awarded 240 b. Days Added by CO C. Total Days 240 it. Days Charged 301 e. Days Remaining -61 Consent of Surety Affidavit of Bills Paid 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. Progress Estimate City Secretary 57093 Contrnct Num' Par (°°ntraa). Daggett and A McRae SRTS Improvements Application Period: 11/21/23-12/05/23 A B C D Item Esmnated Quantity Specification Unit of Bs! Quantity Unrt Pnce Btd Value Value Previously Bid Item Na Description Installed Section No. Measure 1 PREPARING ROW 01006002 STA 145.00000 ff $76.OJ $11,020.Ot1 1450000000 $11,0200(6 1 2 PREPARING ROW (TREE)(12"TO 24"DIA) 01006004 EA 1B.000d $1,800.00 $32,400.0(It 160000000 $28,800.0 1 3 REMOVING CNC (MEDIANS) 0104 6011 SY 10.00000J $120.0% $1,200.06) 5.0000000 ff $600.0 f 1 4 REMOVING COONC (SIDEWALKS) 01046015 SY 2912.000OOU $15.5q $45,136.O�J 2724.6510000(JJ $42,232.OrfJ 1 5 REMOVING CNC (DRIVEWAYS) 0104 6011 SY 2353.000OOU $15.5� $36,471.5(J 2456.7546000(f $38,079.7 1 6 REMOVING COONC (CURB OR CURB & GUTTER) 0104 6029 LF 2773.00000U $10.51\ $29,116.5 J 2764.8490000 J $29,030.91 1 7 REMOVINGCONC(WHEELCHAIR RAMP) 01046032 SY 791.000000 $2&A $22,148.0 770.0090000Q $21,560.2� 1 8 REMOVING CONIC (RETAINING WALLS) 0104 6024 SY 1.000000 $655.A $655.0 JJ 1.0000000 JJ $655.0 J 1 9 REMOVING STAB BASE & ASPH PAV (4") 0105 6074 SY 18.00000('. $51.017 $918ZI 131.33800021 $6,698.24J 1 10 BLOCK SODDING 01626002 SY 6500.00000(I $9.0U $58,600.0 3045.64100000 $27,410.7- 1 11 VLCCON� �FiANGWALL) 04206062 CY �8.50000(I $2,900.00 $$4,350.0� 14966640d $1,862.95 1 12 C a IE7 N J $43,409.06 1 13 RIPRAP(CONC)(41N) 04326001 CY 12.30000(I $565.00 $6,949.50 10800270(f0 $6,102i 1 14 ADJUSTING MANHOLES O4796001 EA 2.00000(I $965.00 $1,930.00 300000000 $2,89500 1 15 ADJUSTING MANHOLES(WATER VALVE BOX) 04796005 EA 27.00000(I $900.00 $24,300.00 1500000000 $13,50000 1 16 ADJUST NG MANHOLES (ELECTRIC BOX) 04796010 EA 1.00000(i $900.00 $900.00 100000000 $90000 1 17 MOBILIZATION 05006001 LS 1.00000(1 $75,000.00 $75.000.00 100000000 $75,00000 1 18 BARRICADES, SIGNS AND TRAFFIC HANDLING 05026001 MO B.00000(1 $5,000.00 $40,000.0-,, 800000000 $40,000.00 19 TEMP CE (INSTALL) 0506 6038 LF 950.00000(I $4A� $3,800.0- I j�j.�QY 0506.1, LF 950.00000(I $1.00 $950.0. 1 1 201 Ti@IlOyy((b (iFJST�) ��) 05066040 LF 950.00000(1 $7.00 $6,650.011 600.0000000 J $4,200.0 1 1 22 CiiNCC G k II) 05296009 LF 1632.00000(1 $45.010 $73,440.011 2325.6690000Q1 $104,655.1 J{ 1 23 DRIVEWAYS(CONC) 05306004 SY 2628.00000(1 $77.04 $202,356.01\ 2575.1226000QJ $198,284A(J 1 24 CONC SIDEWALKS(4") 05316001 SY 4650.00000(1 $62.001 $288,300.0(\ 4179.6978000QJ $259,141.2(J 1 25 CURB RAMPS (TY 1) 0531 6004 EA 16.00000(1 $1,600.001 $25,600.0(\ 6.000OOOOQJ $9,600.0()J 1 26 CURB RAMPS (TY 2) 0531 6005 EA 14.000004 $1,600.04 $22,400.00 13.0000000 $20,800.0(JJ 1 27 CURB RAMPS (TY 3) 0531 6006 EA 2.00000(.I $1,600.04 $3,200.0(` 1.0000000 $1,600.0()J 1 28 CURB RAMPSf 5 0531 6001 EA 1.000000 $3,000.04 $3,000.01 1 OOOO000UI $3,000.0 1 29 CURB RAMPS 7� 05316010 EA 112.000OOU $1,600.00 $179,200.00 960000000 $153,600.00 30 CURB RAMPS166) 05316013 EA 18.000OOU $1,600.00 $28,800.00 17000000(f0 $27,20000 1CONICSIDEWS SPECIAL)(RETAINING WALL) 05316057 SF 2867.000000 $38.00 $108,946.00 385629560000 $148,53923 1 32 CONC MEDIAN 05366002 BY 9.000000 $500.00 $4,500.00 500000000 $2,50000 1 33 REMOVE AND INSTALL EXISTING GATE 01101/11 EA 1.000000 $1,300.00 $1.300.00 1 34 PIPE UNDERDRAINS (TY 8) (6") 0556 6008 LF 13.000000 $118.00 $1,534.00 1 35 IN SM RD SN SUP&AM TYI0BWG(1)$A(P) 06446001 EA 127.000000 $400.00 $50,800.00_ 12700000000 $50,800.00 1 36 RELOCATE SM RD SINSUP&AM TY 1 OBW G 0644.68 EA 61.000000 $500.00 $30.500.0= 57 00000000 $28,500.0 J 1 37 REMOVE SM RD SN SUP&AM 0644 6076 EA 11.000000 $120A $1.320:0, 18.0000000 $2,160.0 1 38 REMOVE SM RD SIN SUP&AM (SIGN ONLY) 0644 6078 EA 1.000000 $40.011 $40.0(i 1 39 REFL PAV MRK TV (W)8"(BRK)(100MIL) 06666027 LF 40.000000 $2.011 $80.0(i 1 40 REFL PAV MRKTY I (W)24"(SLD)(100MIL)/6116/48 LF 7853.000000 $6.011 $47,118.OU 7341.0000000 J $44,046.0 J 1 41 REF PAV MRK TY I(W)18"(YLD TRI)(100MIL) 06666099 EA 25.000000 $29.OQ// $725.OU 24.000OOOOQJ $696.0()J 1 42 REFL PAV MRK TY (Y)8-(SLD)(I00MIQ 06666138 LF 90.000000 $2.OU� $180.00 41.5000000Q $83.0()I 1 43 REFL PAV MRK TY II (W )8. (BRK) 0666 6175 LF 40.000000 $0.251 $10.00' J J 1 44 REFL PAV MRK TY 11 (W) 24" (SLD) 0666 6182 LF 7853.000000 $0.5�1� $3,926.5(- 7341.000OOOOIQQIJ $3,670.5()J 1 45 REFL PAV MRK TY II ((( ))) 18" (YLD TRI) 0666 6198 EA 25.000000 $12.OIf $300.0( 24 0000000 $288.0()��J 1 46 EFL PAV MRK TY } 4 ; D) 0666 6207 LF 10514.00000�J $0.25 $2,628.5r 9785 752000(f0J $2,446. 1 47 REFL PAV MRK TY II }I 8" SLD(S 0666 6211 LF 90.00000() $O.TS $22.:,� 41 500000(f0 $10 38 1 48 RE PM W/RET REO ( )4"(S D)000MIL) 0666 6315 LF 10514.00000 $1.00 $10,514.0- 1 9785 75200000 $9,785 1 49 REFL PAV MRKR TY II -A- 06121001 EA 418.00000 $5.00 $2,090.0- 1 358 00000000 $1,790 00 1 50 ELIM EXT PAV MRK & MRKS (4") 06" 6001 LF 308.00000 $1.00 $308.0- 1 308 00000000 $308 00 1 51 ELIM EXT PAV MRK &MRKS (8") 067761 03 LF 76.00000 $2.00 $152.0- 1 52 ELIM EXT PAV MRK & MRKS (12") 0677 05 LF 138.00000 $2.00 $276.0- 1 1 53 ELIM EXT PAV MRK & MRKS (24") 067760 6007 LF 1293.00000 $2.00 $2,586.Oi 1293 00000000 $2,586.0 1 54 ELIM EXT PAV MRK & MRKS (SYMBOL) 0677.17 EA 4.00000 1 $60.06/ $240.0- 1 55 ELIM EXT PAV MRK & MRKS (18")(YLD TRI) 0677 6018 EA 20.00000U� $21.1U. $500.01 20.0000000) $500.011 1 56 PAV SURF PREP FOR MRK (4") 0678 6001 LF 10514.00000U1 $0,1U' $1,051.4(I 9785.752000001 $978.58) 1 57 PAV SURF PREP FOR MRK (8") 0678 6004 LF 130.00000 $0.2�5 $32.`r. 41.5000000 $10.3 1 58 PAV SURF PREP FOR MRK (24") 0678 6008 LF 7853.00000 1 $0.511 $3,926.50 7341.0000000 1J $3,670.5 JJ 1 59 PAV SURF PREP FOR MRK (18")(YLD TRI) 0678 6022 EA 25.00000(i�1 $12.OQ $300.0U) 24.00000000 $288.OU 1 60 PAV SURF PREP FOR MRK (RPM) 0678 6033 EA 418.00000UI $0.5Q $209.001 358.00000000I $179.0UJ 1 61 TREE PROTECTION 10046001 EA 77.00000 $200.011 $15,400.0 47.0000000 0,400.0 I I This document has bee. modified hom ❑a -ginal form as an EJCDC document and the user did not highlight the modifications. You are encouraged to read the document carefu8y and consult Legal Counsel pnor to its execution. C-620 Unit Price Progress Estimate Contractor's Application Applrcahov Number: 19 Final Application Date: 12/5/2023 E F G Total Compl-d % Balance to Finish petalled Value Value This Pevod M.,m ds Pres-1y and Stored t. Date (P) (B - P) Stored (not vi C) (D+ 8) B $11,020.0 $11,020.OJ 100.0% $28,800.00I $28,800.00 138.9% $3.600.001 $600.00 $600.OJ 50.0% $600.001 $42,232.0 J $42,232.04 93.6% $2.903.911 $38,079.7 $38,079.7J 104.4% -$1,608.201 $29,03N $29,030.91 99.7% $85.591 $21,560.2�JJ $21,560.idl 97.3% $587.751 $655.2QQA $655.0(1 100.0% 1 $ $6,698.24 729.7% -$5,780.241 $27,410.7J $27,410.7/ 46.9% $31,089.231 $1,862.9 � $1,862.9� 16.3% $9,537.051 $43,409.06J $43,409.06 997.9% -$391059.061 $6,102.1 $6,102.15 87.8% $847.351 $2,895.00 $2,895.00 150.0% -$965.001 $13,500.00 $13,500.00 55.6% $10,800.001 $900.00 $900.00 100.0% 1 $75,000.00 $75,000.00 100.0% 1 $40,000.00 $40,000.00 100.0% 1 $3.800.001 $950.001 $4,200.011 $4,200.0J 63.2% $2.450.001 $104,655.11 $104,655.11 142.5% -$31,215.111 $198,284. l $198,284.44 98.0% $4,071.561 $259,141.26J $259,141.2ti 89.9% $29,158.74 $9,600.OUJ $9,600.OJ 37.5% $16,000.00 $20,800.0d $20,800A 92.9% $1,600.00 $1,600.011 $11600.0d 50.0% $1,600.00 $3,000.0 $3,000.011 100.0% 1 $153,600.00 $153,600.00 85.7% $25,600.001 $27,200.00 $27,200.00 94.4% $1,600.001 $146,539.23 $146,539.23 134.5% -$37,593.231 $2,500.00 $2,500.00 55.6% $2,000.001 $1.300.001 $1.534.001 $50,800.00 $50,800.00 100.0% 1 $28,500A0 $28,500.00 93.4% $2.000.001 $2,160.00 $2,160.0d 163.6% -$840.001 $40.00 $80.00 $44,046.0 J $44,046.0J 93.5% $3,072.001 $696.OU1 $696.OJ 96.0% $29.001 $83.0U $83.0(1 46.1% $97.001 $10.001 J1 $3,670.5 1 $3,670.511 93.5% $256.001 $2SIL 10 1f $288.0J 96.0% $12.001 $2,446. $2,446.44 93.1% $182.061 $10.38 $10.38 46.1% $12.131 $9,785.7 $9,785.75 93.1% $728.251 $1,790.00 $1,790.00 85.6% $300.001 $308.00 $308.00 100.0% 1 $152.001 $276.001 $2,5136.00 $2,586.00 100.0% 1 $240.001 $500.0 I $500.0(1 100.0% 1 $978.58 $978.5d 93.1% $72.821 $10.3 J $10A 31.9% $22.13 $3,670.5U1 $3,670.511 93.5% $256.001 $288.OU1 $288.0J 96.0% $12.001 $179.OU1 $179.011 85.6% $30.001 $9,400.011 $9,400.011 61.0% $6,000.001 I I C-620 Unit Price Progress Estimate Progress Estimate citysecretiry 57093 Contractor's Application ConVactN sa Par(°°no-aa). Daggett and A McRae SRTS Improvements Application Namber. 19 Final Application Period: 11/21/23.12/05/23 Application Date: 12/5/2023 A B C D E F G Item Balance to Finiah Bsmnated Quantity Matenals Presently Total Completed Bpecifcahon Unit of Bs! Quantity Unrt Pnce Btd Value Value Previously Installed Value Value This P—od and Stored to Date (F) (B - F) Bid Item No Description Sechov No. Measure Instilled Stored (not m C) (7 E) B Totals $1,531,606.40 $1,483,072.68 $1,483,072.68 $1,483,072.68 96.8% $48,533.721 This document has been modified fom ❑s mginal form es an E1CDC document and the user did not highlight the modifications. You are encouraged n, read the document —My and consult Legal Counsel pnor to its executmn. C-620 Change Order Progress Estimate Change Order Number I 1 I Contractor's Application ADDITIONS For (contra°`)' 102403 Daggett and D. McRae SRTS Improvements City Secretary Contract Num: (Application Period. 11/21/23-12/05/23 A B Item Addition Change Order Item Specification CO QuantiTy to Add Unit Price Change Order No. Description Section No. Unn of Measure Value 62 9608.600 1 Unique Change Order Item Nl Dn—ay Excayatim(UOM DOL) TPW DOL 777.41000000 $1.00 $777.41 57093 C Estimated led Installed 777.41000000 D Value $777.41 Installed Value Palled Value $777.411 Value This Period Application Number. 19 Final Application Date: 12/5/2023 E F Balance to Finish Total CorrrQleted and Stored to Date (F) (B - P) St tall( of in titlC)y Stored (not m C) (D + E) B 1 $777.41 100.0% 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 0 its execution. C-620 Change Order Totals $777.41 $777.41 $777.41 $777.41 100.0% Progress Estimate Change Order Number 1 I Contractor's Application DELETIONS For (contract) 102403 Daggett and D. McRae SRTS Improvements Application Number 19 Final (Application Period 11/21/23-12/05/23 Application Date: 12/5/2023 A B C D B F [rem co Quantity to Deter - Change Order Item Specificafian Description Unit of Measure Delete Una Price Change Order Not Used Not Used Not Used Not Used Not Used Not Used Not Used Not Used No. Section No. Value Totals This document has been modified fivm its original form se an EJCDC document and the user, did not highlight the modifications. You are encouraged to read the document carefully and consult Legal Counsel prior 0 its execution. City Secretary Contract Num: 1 57093 Application Period: Funding Identification (FID) Original Contract 134018-0200431-5740010-102403-003880-9999-18010207 131001-0200431-574001-102403-003880 10 10 10 10 10 10 10 10 10 Change Order 1 134018-0200431-5740010-102403-003880-9999-18010207 131001-0200431-574001-102403-003880 10 10 10 10 10 10 10 10 10 Change Order 2 134018-0200431-5740010-102403-003880-9999-18010207 131001-0200431-574001-102403-003880 10 10 10 10 10 10 10 10 10 Change Order 3 134018-0200431-5740010-102403-003880-9999-18010207 City of Fort Worth Summary of Charqes Daggett and D. McRae SRTS Improvements I p. 0.: F W020-0000007324 11/21/23-12/05/23 I Apphcahon 19 Final Number: Total Completed ' Amt Remaining ' Gross $696,310.56 $786,762.12 $777.41 $22,786.84 $25,746.88 Project Number: 102403 Application Date: 12/5/2023 Retainage Net City of Fort Worth Summary of Charqes City secretary Contract Num: 57093 I Daggett and D. McRae SRTS Improvements I P. 0.: FW020-0000007324 Application Period: 11/21/23-12/05/23 I Application 19 Final Number: Funding Identification (FID) 131001-0200431-574001-102403-003880 10 10 10 10 10 10 10 10 10 Change Order 4 134018-0200431-5740010-102403-003880-9999-18010207 131001-0200431-574001-102403-003880 10 10 10 10 10 10 10 10 10 Change Order 5 134018-0200431-5740010-102403-003880-9999-18010207 131001-0200431-574001-102403-003880 10 10 10 10 10 10 10 10 10 Change Order 6 134018-0200431-5740010-102403-003880-9999-18010207 131001-0200431-574001-102403-003880 10 Total Completed ' Amt Remaining ' Gross Project Number: 102403 Application Date: 12/5/2023 Retainage I Net City of Fort Worth Summary of Charqes City secretary Contract Num: 57093 I Daggett and D. McRae SRTS Improvements I P. 0.: FW020-0000007324 Application Period: 11/21/23-12/05/23 I Application 19 Final Number: Funding Identification (FID) Total Completed ' Amt Remaining ' Gross Change Order 7 134018-0200431-5740010-102403-003880-9999-18010207 131001-0200431-574001-102403-003880 10 10 10 10 10 10 10 10 10 Change Order 8 134018-0200431-5740010-102403-003880-9999-18010207 131001-0200431-574001-102403-003880 10 10 10 10 10 10 10 10 10 Totals 134018-0200431-5740010-102403-003880-9999-18010207 $697,087.97 $22,786.84 131001-0200431-574001-102403-003880 $786,762.12 $25,746.88 10 10 10 Project Number: 102403 Application Date: 12/5/2023 Retainage Net 10 10 10 10 10 10 City Secretary Contract Num: 57093 Application Period: Funding Identification (FID) City of Fort Worth Summary of Charqes Daggett and D. McRae SRTS Improvements I P. 0.: FW020-0000007324 Project Number: 102403 11/21/23-12/05/23 I Application 19 Final Application Date: 12/5/2023 Number: Total Completed I Amt Remaining I Gross Retainage I Net Grand Total 1 1 $1,483,850.09 1 1 $48,533.72 1 1 $0.00 1 1 ($74,192.51)1 1 $74,192.51 1 Texas Contract Time Statement Department of Transportetton Form 252 (Rev. 10/11) Page 1 of 1 ESTIMATE NO. 12 CONTRACTOR Urban Infraconstruction LLC PROJECT NO. STP 2021(953)TP COUNTY TARRANT TIME COMPUTED FROM Days Charged per Calendar day starting on 5/09/2022 DATE WORKING MONTH DAYS DAYS CHARGED May 2022 23 23 June 2022 30 30 July 2022 31 31 Aug 2022 31 31 Sept2022 30 30 Oct 2022 31 31 Nov 2022 30 30 Dec 2022 31 26 Jan 2023 31 27 Feb 2023 13 10 15 0 Mar 2023 31 April 2023 TOTALS 4 28 28 301 DATE WORK BEGAN 05/09/22 DATE WORK COMPLETED 04/28/23 DAYS CREDITED AND REASONS THEREFORE 0 No Credit days - Calendar day project 0 No Credit days - Calendar day project 0 No Credit days - Calendar day project 0 No Credit days - Calendar day project 0 No Credit days - Calendar day project 0 No Credit days - Calendar day project 0 No Credit days - Calendar day project 5 Time Suspension - Dec 23rd to Dec 26th and Dec 31 st - Weather and Holidays 4 Time Suspension - Jan 1 st & 2nd - Weather and Holidays D McRae Preliminary punch list 1/17/2023 Daggett Preliminary punch list 1/18/2023 Time Suspension - Jan 30th & 31st - Freezing Weather 3 Time Suspension - Feb 1st through Feb 3rd - Freezing Weather 15 All work completed as of 2/13/2023. Time being suspended pending TDLR and Final Inspection TDLR Inspection conducted 2/22/2023 Final Inspection conducted 2/27/2023 TDLR Report and Final inspection provided to Contractor 3/6/2023 27 Contractor remobilized 3/20/2023 - 7 days to complete punch list before time resumes (12.2.2) Time resumed 3/28/2023 as punch list is incomplete All Work punchlist work completed as of 4/28/2023 - Time being suspended until TOOT review 54 NO. OF CONTRACT WORKING DAYS 240 NO. OF WORKING DAYS CHARGED TO DATE 301 ASSESSED LIQUIDATED DAMAGES: NO. OF DAYS 61 PER DAY $1,000 TOTAL $ 61,000 CERTIFIED AS CORRECT (ONE COPY HAS BEEN GIVEN TO THE CONTRACTOR) RESIDENT ENGINEER For Instructions and Definitions, Reference the Estimates Manual. CSC No. 57093-COI FOR_ _ T WORTH, City of Fort Worth �•� Change Order Request Project Namel Daggett and D. McRae SRTS Improvements City Sec # l 57093 Client Project #(s)l City Project Number 102403 - TxDOT CSJ 0902-90-083 Project Description) SRTS project improvemnts including construction of new and reconstruction of existing sidewalks, curb ramps, driveways, curb and gutter, small retaining walls, signs, crosswalks and pavement markings within an approximate quarter mile of both the Daggett and D. McRae Elementary School Campuses. Contraclorl Urban Infraconstruction, LLC Change Order#1 1 Datel 12/1212022 City Project Mgr.1 Brendan McInnes, PE City Inspectorl William Toohey Dept. TPW Contract Time Totals (CD) Original Contract Amount $1,531,606.40 $1,531,606.40 240 Extras to Date $0.00 0 Credits to Date $0.00 0 Pending Change Orders (in M&C Process) $0.00 0 Contract Cost to Date $1.531,606.40 $1,531,606.40 240 Amount of Proposed Change Order $777.41 $777.41 0 Revised Contract Amount $1.532,383.81 $1,532,383.81 240 Original Funds Available for Change Orders $153,160.64 $153,160.64 Remaining Funds Available for this CO $153,160.64 $153,160.64 Additional Funding (if necessary) CHANGE ORDERS to DATE (INCLUDING THIS ONE) AS % OF ORIGINAL CONTRACT 0.05% MAX ALLOWABLE CONTRACT AMOUNT (ORIGINAL CONTRACT COST + 25%) $1,914,508.00 JUSTIFICATION (REASONS) FOR CHANGE ORDER This change order is necessary in order to compensate the contractor for excavation of an alley that was not accounted for in the project plans that was required to properly grade a driveway. Contractor submitted RFI 05 requesting clarification of the grading and compensation for this driveway. Engineer reviewed the RFI and provided a solution in their response. Contractor has submitted prices for the added work. Typical methods for comparing unit costs were not available and were not considered adequate for this work. Instead, the City and Contractor agreed to use a Force Account method to track the actual costs. All costs associated with the work including all labor and materials were monitored and documented in order to determine the actual cost of the additional work performed. The documentation has been attached to this change order. It is understood and agreed that the acceptance of this Change Order by the contractor constitutes an accord and satisfaction and represents payment in full (both time and money) for all costs arising out of, or incidental to, the above Change Order. The Project/Program Manager signing below acknowledges that he/she is the person responsible for the monitoring and administration of this contract, including ensuring all performance and reportin�"Dec22,2022 LF Contractor's Company Name Contractor (Name) ontract Signature Urban Infracenslruction, LLC. Anup Tamrakar I'„;,,.„,,,,,,� �Inspector#nspection Supervisor Date Project and Contract Compliance Manager . Dale Dec 22, 2022 —�r Dec 22, 2022 Program Manager Date Senior Capital Project Officer Dale Dec 23, 2022. - -- Jan 3, 2023 )Assistant Director (Dept) Date Director, Contracting Department (Dept) Date Jan 3, 2023 -- Jan 3, 2023 Assistant City Attorney Date Assistant City Manager Date Jan 4,2023 Pan 5,2023 Council Action (if required) M&C Number l M&C Date Approved I ATTEST: Jannette Goodall, City Secretary FORT WORTH City of Fort Worth IT-- Change Order Additions Project Name I Daggett and D. McRae SRTS Improvements 1 Cily Sec # 1 57093 Client Project # I City Project Number 102403-TxDOT CSJ 0902-90-083 1 conlractorl Urban Infraconstruction, LLC PMI Brendan McInnes, PE Inspectorl William Toohey l Change Order Submittal # 0 Date 1 12/1212022 AUDITIONS ITEM UESCRIPIION DEPT 62 9608.6001Unique Change Order Item #1 Ddveway Excavation (UOM: DOL) TPW Oty, Unit Unit Cost Total 1 777.41000000 DOL S1.06 $777.411 I I I I I I I I I I I I I I I I I I I I I I I I I I I I 1 I I 1 I I I I I I I I I I I I I I 1 I 1 I I I 1 I 1 I I I I TOW $777.41 Sub Total Additions $777.41 Change Order Additions Page 2 of 4 FORT WORTH City of Fort Worth '!' Change Order Deletions Project Name I Daggett and D. McRae SRTS Improvements I CitySec # 1 57093 1 Client Project # I City Project Number 102403 - TxDOT CSJ 0902-90-083 1 Contractotl Urban Infraconstmction, LLC I PMl Brendan McInnes, PE Inspectorl William Toohey Change Order Submittal # �J Date 1 1211212022 1 IJE-ETIONS ITEM DESCRIPI[ON - UEPI city Unit ' Unit Cost total 1 I I I I I T♦-W $0.00 Sub Total Deletions $0.00 Change Order Deletions Page 3 of 4 MISBE Sub co # MISBE for this Change Order Type of Service I Amount for this CO Total $0.00 1 Previous Change Orders DATE I AMOUNT Total $0.00 I FORTWORTH. TRANSPORTATION AND PUBLIC WORKS December 1, 2023 Urban Infraconstruction 2512 Gravel Drive. Fort Worth, TX. 76118 RE: Acceptance Letter Project Name: Daggett and D. McRae SRST Improvements Project Type: Paving City Project No.: 102403 To Whom It May Concern: On February 27, 2023 a final inspection was made on the subject project. There were punch list items identified at the time. The punch list items were completed on 4/28/2023. The final inspection and the corrected punch list items indicate that work meets the City of Fort Worth specifications and is therefore accepted by the City. The correction period per General Conditions 00 72 00 section 13.7 will start on 4/28/2023; which is the date of the punch list completion and will extend of two (2) years in accordance with the Contract Documents. If you have any questions concerning this letter of acceptance, please feel free to contact me at (817)392-2817. Sincerely, Brendan Mclnnes Brendan McInnes (Jan 3, 202407:51 CST) Brendan McInnes, Project Manager Cc: William Toohey, Inspector Gary Deyon, Inspection Supervisor Edward Davila, Senior Inspector Chad Allen, Program Manager Kimberly -Horn and Associates, Consultant Urban Infraconstruction, Contractor Fort Worth, Tx, Developer File E-Mail: TPW_Acceptance@fortworthtexas.gov Rev. 08/20/19 CONSENT OF OWNER ❑ SURETY COMPANY ARCHITECT ❑ TO FINAL PAYMENT CONTRACTOR ❑ SURETY ❑ AIA DOCUMENT G707 OTHER Bond No. 2327741 PROJECT: Daggett and D McRae Safe Routes to School Improvements, City Proj. No. 102403, (name, address) Fort Worth, TX TO (Owner) [ City of Fort Worth ] ARCHITECT'S PROJECT NO: 200 Texas Street Fort Worth, TX 76102 CONTRACT FOR: [ ] CONTRACT DATE: December 14, 2021 CONTRACTOR: Urban Infraconstruction, LLC 526 N. Britain Road Irving, TX 75061 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) Swiss Re Corporate Solutions America Insurance Corporation , SURETY COMPANY, 1200 Main St., Suite 800 on bond of (here insert name and address of Contractor) Urban Infraconstruction, LLC 526 N. Britain Road Irving, TX 75061 , CONTRACTOR, hereby approves of the final payment to the Contractors, 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) City of Fort Worth 200 Texas Street Fort Worth, TX 76102 as set forth in the said Surety Company's bond. IN WITNESS WHEREOF, the Surety Company has hereunto set its hand this 28th Attest: (Seal): ,OWNER, day of December 2Q23 Swiss Re Corporate Solutions America Insurance Surety Company -st--rzt_ Signature of Authorized Representaive Sandra Lee Roney Title Attorney -In -Fact NOTE: This form is to be used as a companion doe: ment to AIA DOCUMENT G706, CONTRACTOR'S AFFIDAVIT OF PAYMENT OF DEBTS AND CLAIMS, f Current Edition AIA DOCUMENT G707 • CONSENT OF Si IRETY COMPANY TO FINAL, PAYMENT • APRIL 1970 EDITION • AIA® ONE PAGE © 1970 • THE AMERICAN INSTITUTE OF ARCI-IITEi T S, 1735 New _'ork Ave., NW, WASHINGTON, D.C. 20006 SWISS RE CORPORATE SOLUTIONS SWISS RE CORPORATE SOLUTIONS AMERICA INSURANCE CORPORATION FK/A NORTH AMERICAN SPECIALTY INSURANCE COMPANY ("SRCSAIC") SWISS RE CORPORATE SOLUTIONS PREMIER INSURANCE CORPORATION FK/A WASHINGTON INTERNATIONAL INSURANCE COMPANY ("SRCSPIC") WESTPORT INSURANCE CORPORATION ("WIC") GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, THAT SRCSAIC, a corporation duly organized and existing under laws of the State of Missouri, and having its principal office in the City of Kansas City, Missouri, and SRCSPIC, a corporation organized and existing under the laws of the State of Missouri and having its principal office in the City of Kansas City, Missouri, and WIC, organized under the laws of the State of Missouri, and having its principal office in the City of Kansas City, Missouri, each does hereby make, constitute and appoint: JOHN R. WARD, THOMAS DOUGLAS MOORE, EMILY ALLISON MIKESKA, ALLYSON W. DEAN, MONICA RUBY VEAZEY, JOHN WILLIAM NEWBY, TROY RUSSELL KEY, DEBRA LEE MOON, ANDREA ROSE CRAWFORD, SANDRA LEE RONEY, DANA ILENE MOORE AND COLIN E. CONLY JOINTLY or SEVERALLY Its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the amount of: TWO HUNDRED MILLION ($200,000,000.00) DOLLARS This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of Directors of both SRCSAIC and SRCSPIC at meetings duly called and held on the 18th of November 2021 and WIC by written consent of its Executive Committee dated July 18, 2011. "RESOLVED, that any two of the President, any Managing Director, any Senior Vice President, any Vice President, the Secretary or any Assistant Secretary be, and each or any of them hereby is, authorized to execute a Power of Attorney qualifying the attorney named in the given Power of Attorney to execute on behalf of the Corporation bonds, undertakings and all contracts of surety, and that each or any of them hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Corporation; and it is FURTHER RESOLVED, that the signature of such officers and the seal of the Corporation may be affixed to any such Power of Attorney or to any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be binding upon the Corporation when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached." cOLUTIO;� S EAL�D973 BErik xf ~Lyc�eT�� ����^e� Janssens, Senior Vice President of SRCSAIC & Senior Vice President of SRCSPIC & Senior Vice President of WICBy oaaa°• Gerald Jagrowski, Vice President ofSRCSAIC & Vice President of SRCSPIC & Vice President of WIC IN WITNESS WHEREOF, SRCSAIC, SRCSPIC, and WIC have caused their official seals to be hereunto affixed, and these presents to be signed by their authorized officers this 2nd day of AUGUST 2022 Swiss Re Corporate Solutions America Insurance Corporation State of Illinois Swiss Re Corporate Solutions Premier Insurance Corporation County of Cook ss Westport Insurance Corporation On this 2nd day of AUGUST _ 20 22 , before me, a Notary Public personally appeared Erik Janssens , Senior Vice President of SRCSAIC and Senior Vice President of SRCSPIC and Senior Vice President of WIC and Gerald Jaerowski , Vice President of SRCSAIC and Vice President of SPCSPIC and Vice President of WIC, personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and acknowledged said instrument to be the voluntary act and deed of their respective companies. ,- 7i Yasmin A. Patel, Notary I, Jeffrev Goldbere, the duly elected Senior Vice President and Assistant Secretary of SRCSAIC and SRCSPIC and WIC, do hereby certify that the above and foregoing is a true and cerl•ect Copy of a Power of Attorney given by said SRCSAIC and SRCSPIC and WIC, which is still in full force and effect. IN WITNESS WHEREOF., I have set my hand and affixed the seals of the Companies this 28th day of December 20 23 . Jeffrey Goldberg, Senior Vice President & Assistant Secretary of SRCSAIC and SRCSPIC and WIC IMPORTANT NOTICE In order to obtain information or make a complaint: You may contact Jeffrey Goldberg, Vice President - Claims, at 1-800-338-0753. You may call Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation's toll -free number for information or to make a complaint at: 1-800-338-0753 You may also write to Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation at the following address: 1450 American Lane, Suite 1100 Schaumburg, IL 60173 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1- 800-252-3439 You may write the Texas Department of Insurance: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: httD://www.tdi.state.tx.us E-mail:ConsumerProtection(i�tdi.state.tx. us PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should first contact the Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. AVISO IMPORTANTE Para obtener informacion o para someter un queja: Puede comunicarse con Jeffrey Goldberg, Vice President - Claims, al 1-800-338-0753. Usted puede Ilamr al numero de telefono gratis de Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation's para informacion o para someter una queja al: 1-800-338-0753 Usted tambien puede escribir a Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation al: 1450 American Lane, Suite 1100 Schaumburg, IL 60173 Puede escribir al Departmento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1-800-252-3439 Puede escribir al Departmento de Seguros de Texas: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: httn://www.tdi.state.tx.us E-mail:Cons umerProtection(atdi.state.tx. us DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con el Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation primero. Si no se resuelve la disputa, puede entonces comunicarse con el Departmento de Seguros de Texas. UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de infromacion y no se converte en parte o condicion del documento adjunto. AFFIDAVIT STATE OF l COUNTY OF Before me, the undersigned authority, a notary public in the state and county aforesaid, on this day personally appeared Anup Tamrakar, CEO Of Urban Infraconstruction 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; Daggett And D Mc Rae SaFe Routes To School Improvements, CPN 102403 1 BY VAUV Tamrakar, CEO Subscribed and sworn before me on this date 2nd of January, 2024. j =opNY• UA(c.y NILIMAPOUDEL My Notary ID,, 132686147 -c'-•h� / July 24, 2024 � ��Expires Yublic � Dallas County, TX CONSENT OF OWNER ❑ SURETY COMPANY ARCHITECT ❑ TO FINAL PAYMENT CONTRACTOR ❑ SURETY ❑ AIA DOCUMENT G707 OTHER Bond No. 2327741 PROJECT: Daggett and D McRae Safe Routes to School Improvements, City Proj. No. 102403, (name, address) Fort Worth, TX TO (Owner) [ City of Fort Worth ] ARCHITECT'S PROJECT NO: 200 Texas Street Fort Worth, TX 76102 CONTRACT FOR: [ ] CONTRACT DATE: December 14, 2021 CONTRACTOR: Urban Infraconstruction, LLC 526 N. Britain Road Irving, TX 75061 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) Swiss Re Corporate Solutions America Insurance Corporation , SURETY COMPANY, 1200 Main St., Suite 800 on bond of (here insert name and address of Contractor) Urban Infraconstruction, LLC 526 N. Britain Road Irving, TX 75061 , CONTRACTOR, hereby approves of the final payment to the Contractors, 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) City of Fort Worth 200 Texas Street Fort Worth, TX 76102 as set forth in the said Surety Company's bond. IN WITNESS WHEREOF, the Surety Company has hereunto set its hand this 28th Attest: (Seal): ,OWNER, day of December 2Q23 Swiss Re Corporate Solutions America Insurance Surety Company -st--rzt_ Signature of Authorized Representaive Sandra Lee Roney Title Attorney -In -Fact NOTE: This form is to be used as a companion doe: ment to AIA DOCUMENT G706, CONTRACTOR'S AFFIDAVIT OF PAYMENT OF DEBTS AND CLAIMS, f Current Edition AIA DOCUMENT G707 • CONSENT OF Si IRETY COMPANY TO FINAL, PAYMENT • APRIL 1970 EDITION • AIA® ONE PAGE © 1970 • THE AMERICAN INSTITUTE OF ARCI-IITEi T S, 1735 New _'ork Ave., NW, WASHINGTON, D.C. 20006 SWISS RE CORPORATE SOLUTIONS SWISS RE CORPORATE SOLUTIONS AMERICA INSURANCE CORPORATION FK/A NORTH AMERICAN SPECIALTY INSURANCE COMPANY ("SRCSAIC") SWISS RE CORPORATE SOLUTIONS PREMIER INSURANCE CORPORATION FK/A WASHINGTON INTERNATIONAL INSURANCE COMPANY ("SRCSPIC") WESTPORT INSURANCE CORPORATION ("WIC") GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, THAT SRCSAIC, a corporation duly organized and existing under laws of the State of Missouri, and having its principal office in the City of Kansas City, Missouri, and SRCSPIC, a corporation organized and existing under the laws of the State of Missouri and having its principal office in the City of Kansas City, Missouri, and WIC, organized under the laws of the State of Missouri, and having its principal office in the City of Kansas City, Missouri, each does hereby make, constitute and appoint: JOHN R. WARD, THOMAS DOUGLAS MOORE, EMILY ALLISON MIKESKA, ALLYSON W. DEAN, MONICA RUBY VEAZEY, JOHN WILLIAM NEWBY, TROY RUSSELL KEY, DEBRA LEE MOON, ANDREA ROSE CRAWFORD, SANDRA LEE RONEY, DANA ILENE MOORE AND COLIN E. CONLY JOINTLY or SEVERALLY Its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the amount of: TWO HUNDRED MILLION ($200,000,000.00) DOLLARS This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of Directors of both SRCSAIC and SRCSPIC at meetings duly called and held on the 18th of November 2021 and WIC by written consent of its Executive Committee dated July 18, 2011. "RESOLVED, that any two of the President, any Managing Director, any Senior Vice President, any Vice President, the Secretary or any Assistant Secretary be, and each or any of them hereby is, authorized to execute a Power of Attorney qualifying the attorney named in the given Power of Attorney to execute on behalf of the Corporation bonds, undertakings and all contracts of surety, and that each or any of them hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Corporation; and it is FURTHER RESOLVED, that the signature of such officers and the seal of the Corporation may be affixed to any such Power of Attorney or to any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be binding upon the Corporation when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached." cOLUTIO;� S EAL�D973 BErik xf ~Lyc�eT�� ����^e� Janssens, Senior Vice President of SRCSAIC & Senior Vice President of SRCSPIC & Senior Vice President of WICBy oaaa°• Gerald Jagrowski, Vice President ofSRCSAIC & Vice President of SRCSPIC & Vice President of WIC IN WITNESS WHEREOF, SRCSAIC, SRCSPIC, and WIC have caused their official seals to be hereunto affixed, and these presents to be signed by their authorized officers this 2nd day of AUGUST 2022 Swiss Re Corporate Solutions America Insurance Corporation State of Illinois Swiss Re Corporate Solutions Premier Insurance Corporation County of Cook ss Westport Insurance Corporation On this 2nd day of AUGUST _ 20 22 , before me, a Notary Public personally appeared Erik Janssens , Senior Vice President of SRCSAIC and Senior Vice President of SRCSPIC and Senior Vice President of WIC and Gerald Jaerowski , Vice President of SRCSAIC and Vice President of SPCSPIC and Vice President of WIC, personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and acknowledged said instrument to be the voluntary act and deed of their respective companies. ,- 7i Yasmin A. Patel, Notary I, Jeffrev Goldbere, the duly elected Senior Vice President and Assistant Secretary of SRCSAIC and SRCSPIC and WIC, do hereby certify that the above and foregoing is a true and cerl•ect Copy of a Power of Attorney given by said SRCSAIC and SRCSPIC and WIC, which is still in full force and effect. IN WITNESS WHEREOF., I have set my hand and affixed the seals of the Companies this 28th day of December 20 23 . Jeffrey Goldberg, Senior Vice President & Assistant Secretary of SRCSAIC and SRCSPIC and WIC IMPORTANT NOTICE In order to obtain information or make a complaint: You may contact Jeffrey Goldberg, Vice President - Claims, at 1-800-338-0753. You may call Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation's toll -free number for information or to make a complaint at: 1-800-338-0753 You may also write to Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation at the following address: 1450 American Lane, Suite 1100 Schaumburg, IL 60173 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1- 800-252-3439 You may write the Texas Department of Insurance: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: httD://www.tdi.state.tx.us E-mail:ConsumerProtection(i�tdi.state.tx. us PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should first contact the Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not become a part or condition of the attached document. AVISO IMPORTANTE Para obtener informacion o para someter un queja: Puede comunicarse con Jeffrey Goldberg, Vice President - Claims, al 1-800-338-0753. Usted puede Ilamr al numero de telefono gratis de Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation's para informacion o para someter una queja al: 1-800-338-0753 Usted tambien puede escribir a Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation al: 1450 American Lane, Suite 1100 Schaumburg, IL 60173 Puede escribir al Departmento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1-800-252-3439 Puede escribir al Departmento de Seguros de Texas: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: httn://www.tdi.state.tx.us E-mail:Cons umerProtection(atdi.state.tx. us DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con el Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation primero. Si no se resuelve la disputa, puede entonces comunicarse con el Departmento de Seguros de Texas. UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de infromacion y no se converte en parte o condicion del documento adjunto. AFFIDAVIT STATE OF l COUNTY OF Before me, the undersigned authority, a notary public in the state and county aforesaid, on this day personally appeared Anup Tamrakar, CEO Of Urban Infraconstruction 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; Daggett And D Mc Rae SaFe Routes To School Improvements, CPN 102403 1 BY VAUV Tamrakar, CEO Subscribed and sworn before me on this date 2nd of January, 2024. j =opNY• UA(c.y NILIMAPOUDEL My Notary ID,, 132686147 -c'-•h� / July 24, 2024 � ��Expires Yublic � Dallas County, TX