HomeMy WebLinkAboutContract 47679-FP2 Departent f P&W Const.Services
Cpm � Dat
Project snag ~'
Risk Management Wady deRT W � SD.O.E. Brotherton JH� CSEC
CFA Morales/Scanned L ` r --
*� CONTRACT N0.
Gutzler/Scanned
The Proceeding people have been Contacted
concerning the request for final payment&have "ATION AND PUBLIC WORKS
released this project for such payment. >F PROJECT COMPLETION
Developer Projects)
Clearance Conducted By fi hl�„«J) �I�� ty Project NO: 100059
//7 Ci
C�A &ffy1 L C5#41176'7
Regarding contract 100059 for THE VILLAGES OF EAGLE MOUNTAIN-STORM DRAIN as required by the
TRANSPORTATION AND PUBLIC WORKS DEPARTMENT as approved by City Council on N/A through
M&C N/A the director of the TRANSPORTATION AND PUBLIC WORKS DEPARTMENT upon the
recommendation of the Assistant Director of the Transportation&Public Works Department has accepted the project
as complete.
Original Contract Price: $866,683.00
Amount of Approved Change Orders: NQ 1
Revised Contract Amount: $866,683.00
Total Cost Work Completed: $866,683.00
Re ommended for Acceptance Date
Asst. Director, TPW - Infrastructure Design and Construction
440112
Accepted Date
la Director,
TRANSPORTATION AND PUBLIC WORKS DEPARTMENT
Asst. City anager Date
" �MAZZZ"
Comments: APR 2 7 2017
OFFICIAL RECORD
CITY SECRETARY 1
: .9/22/16 FT.WORTH,TX � j� f
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name THE VILLAGES OF EAGLE MOUNTAIN
Contract Limits PHASE 1I
Project Type STORM DRAIN
City Project Numbers 100059
DOE Number 0059
Estimate Number 1 Payment Number I For Period Ending 3/21/2017
CD
City Secretary Contract Number Contract Time 15CLD
Contract Date Days Charged to Date 319
Project Manager NA Contract is 100.00 Complete
Contractor GILCO CONTRACTING,INC.
6331 SOUTHWEST BLVD.
BENBROOK, TX 76132-1063
Inspectors DICKINSON / WATSON
I
Friday,March 24,2017 Page 1 of 5
City Project Numbers 100059 DOE Number 0059
Contract Name THE VILLAGES OF EAGLE MOUNTAIN Estimate Number I
Contract Limits PHASE 11 Payment Number I
Project Type STORM DRAIN For Period Ending 3/21/2017
Project Funding
STORM DRAIN
Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed
No. Quanity Total Quanity Total
1 REMOVE RIP RAP 549 SF $0.50 $274.50 549 $274.50
2 REMOVE 4'DROP INLET 2 EA $900.00 $1,800.00 2 $1,800.00
3 REMOVE HEADWALL I EA $800.00 $800.00 1 $800.00
4 TRENCH SAFETY 6023 LF $0.50 $3,011.50 6023 $3,011.50
5 CONCRETE COLLAR 11 EA $300.00 $3,300.00 11 $3,300.00
6 18"RCP 126 LF $39.00 $4,914.00 126 $4,914.00
7 21"RCP 414 LF $45.00 $18,630.00 414 $18,630.00
8 24"RCP 2219 LF $54.00 3119,826.00 2219 $119,826.00
9 27"RCP 408 LF $55.00 $22,440.00 408 $22,440.00
10 30"RCP 356 LF $61.00 $21,716.00 356 $21,716.00
11 36"RCP 290 LF $81.00 $23,490.00 290 $23,490.00
12 42"RCP 300 LF $106.00 $31,800.00 300 $31,800.00
13 48"RCP 271 LF $126.00 $34,146.00 271 $34,146.00
14 4X4 BOX CULVERT 987 LF $184.00 $181,608.00 987 $181,608.00
15 5X3 BOX CULVERT 143 LF $198.00 $28,314.00 143 $28,314.00
16 6X4 BOX CULVERT 509 LF $262.00 $133,358.00 509 $133,358.00
17 6'STORM JUNCTION BOX 2 EA $4,500.00 $9,000.00 2 $9,000.00
18 10'CURB INLET 17 EA $3,400.00 $57,800.00 17 $57,800.00
19 10'CURB INLET 5'DEPTH 1 EA $3,500.00 $3,500.00 1 $3,500.00
20 15'CURB INLET 7 EA $4,700.00 $32,900.00 7 $32,900.00
21 20'CURB INLET 3 EA $5,900.00 $17,700.00 3 $17,700.00
22 4'DROP INLET 5 EA $4,400.00 $22,000.00 5 $22,000.00
23 JUNCTION BOX 1 EA $5,900.00 $5,900.00 1 $5,900.00
24 4'STORM MANHOLE 6 EA $3,850.00 $23,100.00 6 $23,100.00
25 Y STORM MANHOLE 1 EA $4,300.00 $4,300.00 1 $4,300.00
26 2-18"SLOPED END HEADWALL 1 EA $2,200.00 $2,200.00 1 $2,200.00
27 36"SLOPED END HEADWALL 1 EA $2,100.00 $2,100.00 1 $2,100.00
28 2-4'X4'SLOPED END HEADWALL 1 EA $8,400.00 $8,400.00 1 $8,400.00
29 5'X3'SLOPED END HEADWALL I EA $7,400.00 $7,400.00 1 $7,400.00
30 DUAL 18"SH FW 0 HEADWALL I EA $2,400.00 $2,400.00 1 $2,400.00
31 TYPE A 12"RIPRAP 535 SY $53.00 $28,355.00 535 $28,355.00
Friday,March 24,2017 Page 2 of 5
City Project Numbers 100059 DOE Number 0059
Contract Name THE VILLAGES OF EAGLE MOUNTAIN Estimate Number I
Contract Limits PHASE 11 Payment Number I
Project Type STORM DRAIN For Period Ending 3/21/2017
Project Funding
32 4'ACCESS PORT 3 EA $1,200.00 $3,600.00 3 $3,600.00
33 CONNECT INLET TO EXISTING RCP 3 EA $200.00 $600.00 3 $600.00
34 DETENTION POND OUTFALL STRUCTURE 1 EA $6,000.00 $6,000.00 1 $6,000.00
Sub-Total of Previous Unit $866,683.00 $866,683.00
Friday,March 24,2017 Page 3 of 5
City Project Numbers 100059 DOE Number 0059
Contract Name THE VILLAGES OF EAGLE MOUNTAIN Estimate Number I
Contract Limits PHASE II Payment I
Project Type STORM DRAIN For ro Ending 3/21/2017
Project Funding C:
Contract Information Summary
Original Contract Amount $866,683.00
Chance Orders
Total Contract Price $866,683.00
JA�P—
Date 3- —J Total Cost of Work Completed $866,683.00
Col tr ctor Less %Retained $0.00
Date Net Earned $866,683.00
Earned This Period $866,683.00
h pect"Suppervisor
Retainage This Period $0.00
ate Less Liquidated Damages
r sect ManageLr
Days @ /Day $0.00
kab-d Date v— LessPavement Deficiency $0.00
less Director/TP/W-IJnfrastruc ire Design and donstruction Less Penalty $0.00
Date / Less Previous Payment $0.00
Direc r/Contracting Depart ent Plus Material on Hand Less 15% $0.00
Balance Due This Payment $866,683.00
Friday,March 24,2017 Page 4 of 5
City Project Numbers 100059 DOE Number 0059
Contract Name THE VILLAGES OF EAGLE MOUNTAIN Estimate Number I
Contract Limits PHASE 11 Payment Number I
Project Type STORM DRAIN For Period Ending 3/21/2017
Project Funding
Project Manager NA City Secretary Contract Number
Inspectors DICKINSON / WATSON Contract Date
Contractor GILCO CONTRACTING,INC. Contract Time 150 CD
6331 SOUTHWEST BLVD. Days Charged to Date 319 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 _
Total Cost of Work Completed $866,683.00
Less %Retained $0.00
Net Earned $866,683.00
Earned This Period $866,683.00
Retainage This Period $0.00
Less Liquidated Damages
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 $866,683.00
Friday,March 24,2017 Page 5 of 5
FORTWORTH rev 03/05/07
TRANSPORTATION & PUBLIC WORKS
FINAL STATEMENT OF CONTRACT TIME
FINAL STATEMENT NO.:1
NAME OF PROJECT: The Villages Of Eagle Mountain
PROJECT NO.: 100059 CONTRACTOR: Burnsco Construction,Inc.
DOE NO.. 59
PERIOD FROM:05/09/16 TO: 03/16/17 FINAL INSPECTION DATE: 16-Mar-17
WORK ORDER EFFECTIVE:3/24/2017 CONTRACT TIME: 319 O Wg* 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 0 0 0 0 319 319
PERIOD
PREVIOUS 0 0 0 0 0 0
PERIOD
TOTALS 0 0 0 0 319 319
TO DATE
*REMARKS;
CONT CTOR DATE INSPECTOR DATE
_ ENGINEERING DEPARTMENT
i The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX 76012-6311
(817)392-7941 •Fax: (817)392-7845
FORTV1® L T�� REV:02/22/07
TRANSPORTATION AND PUBLIC WORKS
CONTRACTOR'S EVALUATION OF CITY
I)PROJECT INFORMATION Date: 3/28/2017
Nance of Contractor Project Name
Burnsco Construction,Inc. The Villages of Eagle Mountain
DOE Inspector Project Manager
Don Watson Sahu Gopal
DOE Number ProjectDculty Tjpe of Contract
100059 O Simple Q Routine Q Complex ❑ Water❑ Waste Watei 1 Storm Drainage( Pavement
Initial Contract Amount Final Contract Amount
$866,683.00 $866,683.00
Il)PERFORMANCE EVALUATION
0-Inadequate 1 -Deficient 2-Standard 3 -Good 4-Excellent
ELEMENT RATING ELEMENT RATING
(0-4)_ (0-4)
]INSPECTION EVALUATION PLANS&SPECIFICATIONS
I Availability of Inspector I 1 Accuracy of Plans to Existing Conditions
2 Knowledge of Inspector q 2 Clarity& Sufficiency of Details
3 Accuracy of Measured Quantities 3 Applicability of Specifications 3
4 Display Of Professionalism 4 Accuracy of Plan Quantities
5 Citizen Complaint Resolution PROJECT MANAGER EVALUATION
6 Performance- Setting up Valve Crews, Labs 1 Knowledge And/Or Problem Resolution
ADMINISTRATION 12 Availability of Project Manager
1 Change Order Processing Time 3 Communication
2 Timliness of Contractor Payments 14 Resolution of Utility Conflicts
3 Bid Opening to Pre-Con Meeting Timeframe
III)COMMENTS&SIGNATURES
COMMENTS
Signature Contractor
Signature DOE Inspector �`'''�
Signature DOE Inspector's Supervisor
INSPECTOR'S COMMENTS
TRANSPORTATION AND PUBLIC WORKS
, F? The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX 76012-6311
(817)392-7941 •Fax: (817)392-7845
REV:02/20/07
TRANSPORTATION AND PUBLIC WORKS
PERFORMANCE EVALUATION OF CONTRACTOR
1) CONTRACTOR&PROJECT DATA
Name of Contractor Project Name
Burnsco Construction Inc. The Villages of Eagle Mountain
DOE Inspector DOE Number
Don Watson 100059
DOE Inspector Project Manager
❑ Water❑ Waste Water❑✓ Storm Drainage❑ Pavement Sahu Gopal
Initial Contract Aniount Project Dififtulty
$866,683.00 0 Simple Routine 0 Complex
Final Contract Amount Date
$866,683.00 3/28/2017
Ili)PERFORMANCE EVALUATION
0-Inadequate 1-Deficient 2-Standard 3-Good 4-Excellent
ELEMENT WEIGHT(x) APPLICABLE(Y/N) RATING(0-4) MAX SCORE SCORE
1 Submission of Documents 2 Y 4 8 8
2 Public Notifications 5 Y 3 20 15
3 Plans on Site 5 Y 4 20 20
4 Field Supervision 15 Y 4 60 60
5 Work Performed 15 Y 4 60 60
6 Finished Product 15 Y 4 60 60
7 Job Site Safety 15 Y 4 60 60
8 Traffic Control Maintenance 15 Y 4 60 60
9 Daily Clean Up 5 Y 3 20 15
10 Citizen's Complaint Resolution 5 Y 4 20 20
11 Property Restoration 5 Y 4 20 20
12 After Hours Response 5 Y 4 20 20
13 Project Completion 5 N
TOTAL ELEMENT SCORE(A) 418
BONUS POINTS(25 Maximum)(B)
TOTAL SCORE(TS) 418
III)CONTRACTOR'S RATING
Maximum Score(MS)=448 or sum of applicable element score maximums which= 428
Rating(ITS/MS] x 100%) 418 { 428 = 98%
Performance Category Excellent
<20%=Inadequate 20%to<40%=Deficient 40%to<60%=Standard 60%to<80%=Good >_80%=Excellent
Inspector's Comments(INCLUDING EXPLANATION OF BONUS POINTS AWARDED)
Signature DOE Inspector s--� Signature Contractor
Signature DOE Inspector's Supervisor
CONTRACTOR'S COMMENTS
TRANSPORTATION AND PUBLIC WORKS
�, 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 ❑
Conforms with the American Institute of OTHER
Architects, AIA Document G707
Bond No 022054638
PROJECT: The Villages of Eagle Mountain Phase II
(name, address) Fort Worth Texas
TO (Owner)
ID.R. HORTON-TEXAS,LTD AND CITY OF FORT ARCHITECT'S PROJECT N0:
WORTH CONTRACT FOR:
6751 North Freeway The Villages of Eagle Mountain Phase II-Water,Sanitary Sewer and
Storm Drainage Improvements
Fort Worth TX 76131 CONTRACT DATE:
CONTRACTOR: BURNSCO CONSTRUCTION, INC.
In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above,the
there 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)
BURNSCO CONSTRUCTION, 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)
D.R. HORTON-TEXAS, LTD AND CITY OF FORT WORTH
6751 North Freeway
Fort Worth TX 76131 , OWNER,
as set forth in the said Surety Company's bond.
IN WITNESS,WHEREOF,
the Surety Company has hereunto set its hand this 9th day of March, 2017
LIBERTY MUTUAL INSURANCE COMPANY
>� SurRy Company
Attest: ally A:'Westbmok
ao&� 16�
(Seal): Signa re of Authorized Representative
Sophinie Hunter Attorney-in-Fact
Title
NOTE; This form 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.7555759
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,
Don E Cornell;Kelly A Westbrook; Ricardo J.Reyna'Robbi Morales;Sophinie Hunter;Tina McEwan;V.DeLene Marshall
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 30th day of November 2016
10
M
�ZY INsU %Nsut k%Nsul
yJ?oePp�>�97 J,�J�JRao��G�rfi �F�Gr�oua;yT��� The Ohio Casualty Insurance Company
Liberty Mutual Insurance Company
p 1919 n >
1912 11 1991 a _
� West American Insurance Company
d * h
�+ By.
C STATE OF PENNSYLVANIA ss David M.Care ,Assistant Secretary M
+_M COUNTY OF MONTGOMERY _
d0Y On this 30th day of November 2016 before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance v H
v 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 purposesLU
p 2 therein contained by signing on behalf of the corporations by himself as a duly authorized officer. d
` M E E
d > 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. oo
9a PAsr COMMONWEALTH OF PENNSYLVANIA ////��\ �) Q
Qti��Aot+w���! Notarial Seal i�'"`/'y" w-d
•� ti� �=y Teresa Pastella,Notary Public By: �(�! O
tC of Upper Merion Twp.,Montgomery County Teresa Pastella,Notary Public
O �. y \p My Commission Expires March 28,2017 3
O �'pT LSP JG Member,Pennsylvania Association of Notaries O
++ ARy Pili Irl.
CM 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 N
Insurance Company,and West American Insurance Company which resolutions are now in full force and effect reading as follows: r ..
CD
L 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 O
a; 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, m
O•S 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 =p
E r 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 '�
L.O 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 attorney-in-fact under >
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.
M C 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, ,
Land 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, L
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 C o
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 v
executed such instruments shall be as binding as if signed by the president and attested by the secretary. O
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 correct copy of the Power of Attorney executed by said Companies, is in full force and effect and
has not been revoked. 4
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this day of ' ' `t-t/' 20 1 r7
INS
eJP�.Pp�,,92t1
a 1919 1912 ° 1497 By:
Renee C.Liew , ssistant Secretary
J�ZfrYHA:A45�G 'da 9�)��SSACHl1���! MDIAYP !
242 of 300
LMS 12873 082016
0 Liberty
� mutuil.
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 informacion 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 19406-2755 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 (111-1A) de Texas Consumer Protection (111-1A)
P. O. Box 149091 P. O. Box 149091
Austin, TX 78714-9091 Austin, TX 78714-9091
FAX: (512) 490-1007 FAX# (512) 490-1007
Web: http://www.tdi.texas.gov Web: http://www.tdi.texas.gov
E-mail: ConsumerProtection@tdi.texas.gov E-mail: ConsumerProtectionnatdi texas.gov
PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS O 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 agente 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.
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 Ab Grantges,
Contract Mgr, Of Bumsco construction, 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 full;
That there are no claims pending for personal injury and/or
property damages;
On Contract described as;
Villages of Eagle Mountain Ph. 2- Water, Sanitary Sewer and Storm Drain
i ;
BY � ' y
Ab Grantges, Con ract Manager
Subscribed and sworn before me on this date 15th of March, 2017.
i
MARY PANNELL
,.`�rf�Y POAg4
Notary Public,State of Texas �
i
Comm. Expires 10-19-2018
Not Public '�,,°;;��° Notary ID 5144239
Tarrant County, Texas