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Contract 48407-FP1
Department o TPW Const. Services CPN# Date Project Manager cc,1,1, LA_ I— —t% tTWORTH, Risk Management S. Gatewood ?--I— D.O.E. Brotherton CITY SECRETARY Water V. Gutzier 7��'' l 494og-PP oo"� CONTRACT NO. J1 CFA Janie Morales/Scanned ❑ kTION AND PUBLIC WORKS —��( E PROJECT COMPLETION 5-q(vo 100419y The Proceeding people have been Contacted concerning the request )eveloper Projects) for final payment&have released this project for such payment. City Project Ns: 100485 Clearance Conducted>Y Etta Sacv _ eS `S� Ory Regarding contract 100485 for VICTORY AT HERITAGE-WATER&SEWER as required by the WATER DEPARTMENT as approved by City Council on N/A through M&C N/A the director of the WATER DEPARTMENT upon the recommendation of the Assistant Director of the Transportation&Public Works Department has accepted the project as complete. Original Contract Price: $388,618.03 Amount of Approved Change Orders: ($33,218.39) N9 1-5 Revised Contract Amount: $355,399.64 Total Cost Work Completed: �3 r l _ Recommend cceptance Date Asst. Direct T W - Development Services I'P Accepted Date Asst. Director, WATER DEPARTMENT 4� l� Asst. City Manager Date OFFICIAL RECORD Comments` CITY SECRETARY hm ��C - FT.WORTH,Tx Rev.9/22/16 City Project Numbers 100485 DOE Number 0485 Contract Name VICTORY AT HERITAGE Estimate Number I Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 3/30/2018 Project Funding Project Manager NA City Secretary Contract Number Inspectors DICKINSON / CHAMBERS Contract Date Contractor PCI CONSTRUCTION,INC. Contract Time 270 CD P.O.BOX 2967 Days Charged to Date CD McKINNEY, TX 75070 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 $355,399.65 Less %Retained $0.00 Net Earned $355,399.65 Earned This Period $355,399.65 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 $355,399.65 Tuesday,April 3,2018 Page 5 of 5 FORT WORTH CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name VICTORY AT HERITAGE Contract Limits Project Type WATER&SEWER City Project Numbers 100485 DOE Number 0485 Estimate Number 1 Payment Number 1 For Period Ending 3/30/2018 CD City Secretary Contract Number Contract Time 270rD Contract Date Days Charged to Date Project Manager NA Contract is 100.00 Complete Contractor PCI CONSTRUCTION,INC. P.O.BOX 2967 MCKINNEY, TX 75070 Inspectors DICKINSON / CHAMBERS Tuesday,April 3,2018 Page 1 of 5 City Project Numbers 100485 DOE Number 0485 Contract Name VICTORY AT HERITAGE Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 3/30/2018 Project Funding WATER Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total I REMOVE 12"WATER LINE(CO#2&3) 255 LF $11.75 $2,996.25 255 $2,996.25 2 4"-12"WATER ABANDONMENT PLUG 2 EA $525.00 $1,050.00 2 $1,050.00 5 6"WATER PIPE(CO#4&5) 278 LF $20.50 $5,699.00 278 $5,699.00 6 8"WATER PIPE(CO#4&5) 42 LF $28.50 $1,197.00 42 $1,197.00 7 12"WATER PIPE(CO#4) 2006 LF $34.50 $69,207.00 2006 $69,207.00 8 FIRE HYDRANT(CO#4) 5 EA $3,275.00 $16,375.00 5 $16,375.00 9 CONNECTION TO EXISTING 4"-12"WATER 2 EA $1,200.00 $2,400.00 2 $2,400.00 MAIN 10 2"WATER SERVICE(CO#4&5) 22 EA $1,877.63 $41,307.86 22 $41,307.86 11 6"GATE VALVE(CO#4&5) 12 EA $1,075.00 $12,900.00 12 $12,900.00 12 8"GATE VALVE(CO#1) 1 EA $1,500.00 $1,500.00 1 $1,500.00 13 12"GATE VALVE(CO#4&5) 12 EA $2,335.00 $28,020.00 12 $28,020.00 14 DUCTILE IRON WATER FITTINGS 3.2 TN $6,551.28 $20,964.10 3.2 $20,964.10 W/RESTRAINT(CO 44) 15 TRENCH SAFETY(CO#4) 2251 LF $0.15 $337.65 2251 $337.65 Sub-Total of Previous Unit $203,953.86 $203,953.86 SEWER Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total ----------------------------------------- 1 REMOVE CONC PVMT 12 SY $30.00 $360.00 12 $360.00 2 CONC PVMT REPAIR RESIDENTIAL 12 SY $140.00 $1,680.00 12 $1,680.00 3 6"SEWER SERVICE(CO#4) 306 LF $29.00 $8,874.00 306 $8,874.00 4 8"SEWER PIPE(CO#4) 1782 LF $31.00 $55,242.00 1782 $55,242.00 5 EPDXY MANHOLE LINER 12 VF $91.67 $1,100.04 12 $1,100.04 6 4"MANHOLE 11 EA $4,400.00 $48,400.00 11 $48,400.00 7 MANHOLE VACUUM TESTING 11 EA $100.00 $1,100.00 11 $1,100.00 8 TRENCH WATER STOP 11 EA $250.00 $2,750.00 11 $2,750.00 9 IMPORTED EMBEDMENT/BACKFILL CSS(CO 67 CY $80.00 $5,360.00 67 $5,360.00 #4) 10 CONCRETE ENCASEMENT FOR UTILITY PIPES 175 CY $63.77 $11,159.75 175 $11,159.75 11 TRENCH SAFETY(CO 44) 2088 LF $0.50 $1,044.00 2088 $1,044.00 Tuesday,April 3,2018 Page 2 of 5 City Project Numbers 100485 DOE Number 0485 Contract Name VICTORY AT HERITAGE Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 3/30/2018 Project Funding 12 POST CCTV INSPECTION(CO 44) 2088 LF $2.00 $4,176.00 2088 $4,176.00 13 TRAFFIC CONTROL 1 MO $6,000.00 $6,000.00 1 $6,000.00 14 CONNECT EXISTING 4'MANHOLE 1 EA $2,400.00 $2,400.00 1 $2,400.00 15 REMOVE 4'SEWER MANHOLE(CO#1) 1 EA $1,800.00 $1,800.00 1 $1,800.00 Sub-Total of Previous Unit $151,445.79 $151,445.79 --------------------------------------- Tuesday,April 3,2018 Page 3 of 5 City Project Numbers 100485 DOE Number 0485 Contract Name VICTORY AT HERITAGE Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 3/30/2018 Project Funding Contract Information Summary Original Contract Amount $388,618.03 Change Orders Change Order Number 1 $2,293.50 Change Order Number 2 ($5,240.50) Change Order Number 3 $2,502.75 Change Order Number 4 ($48,143.16) Change Order Number 5 $15,369.02 Total Contract Price $355,399.65 Date Total Cost of Work Completed $355,399.65 Contractor Less %Retained $0.00 Date b¢ Cb Net Earned $355,399.65 l/ Supe isor / Earned This Period $355,399.65 i f! Retainage This Period $0.00 ' Date Less Liquidated Damages t aFTnft Days @ /Day $0.00 Date r LessPavement Deficiency $0.00 Asst.D cture Desib and Const �cttion Less Penalty $0.00 Date 4/9 �l/ Less Previous Payment $0.00 Director/Contracting Department Plus Material on Hand Less 15% $0.00 Balance Due This Payment $355,399.65 Tuesday,April 3,2018 Page 4 of 5 004243 DAP-BID PROPOSAL P.ge 1 0172 SECTION 00 42 43 Developer Awarded Projects-PROPOSAL FORM UNIT PRICE BID Bidder's Application Revised March 28,2018 Project Item Inforniation Bidder's Proposal Bidlist Item Specification Unit of Bid No. Description Section No. Measure Quantity Unit Price Bid Value UNIT I:WATER IMPROVEMENTS 1 0241.1015 Remove 12 Water Line 0241 14 LF 446 $11.75 $5,240.50 2 0241 1218 4 1-2-"-Water Abandonment Plug 02 41 14 EA 2 $525.00 $1,050.00 3 3305 0005 12 Waterline Lowering 33 05 12 EA 1 $4,080.00 $4,080_00 4 3311 0041 4 Water Pipe 33111110 LF 26 $20.50 $533.00 5 3311.6141&6 Water Pipe 3311 10 LF 211 $20.50 $4,325_.50 6 3311 0241 8 Water Pipe 33 1010 LF 202 $28.50 $5,757.00 7 3311 0441 12 Water Pipe 3311 10 LF 2040 $34.50 $70,380.00 8 3312 0001 Fire Hydrant 33 12 40 EA 6 $3,275.00 $19,650.00 9 3312.0117 Connection to Existing 4"-12"Water Main 331225- EA 2 $1,200.00 $2,400.00 2" _. _ 10 3312 2203 Water Service 33 12 10 EA 19 $1,877.63 $35,674.97 11 3312 30026 GateValve 33 12 20 EA 13 $1 075.00 $13,975.00 12 3312 3003 8 Gate Valve 33 1220 EA 2 $1,500.00 $3,000,00 13 3312.3005 12 Gate Valve 33 1220 EA 17 $2,335.00 $39,695.00 14 3311 0001 Ductile Iron Water Fittings w/Restraint 3311 11 TON 5.8 $6,551.28 $37,997.42 15 3305.0109 Trench Safety 33 05 10 LF 2479 $0.15 $371.85 TOTAL UNIT I:WATER IMPROVEMENTS $244,130.24 UNIT II:SANITARY SEWER IMPROVEMENTS 1 0241.1000 Remove Conc.Pvmt 0241 14 SY 12 $30.00 $360.00 3 3201.0614 Conc.Pvmt.Repair,Residential 32 01 29 SY 12 $140.00 $1,680.00 5 333t3201 6 Sewer Service 33 11 10 LF 238 $29.00 $6,9 2 00 6 3331 4115 e Sewer Pipe 3311 10 LF 1766 $31.00 $54,746.00 7 3339 0001 Epoxy Manhole Liner 33 31 70 VF 12 $91.67 $1,100.04 -- - - - -- --- -- - 8 3339.10014"Manhole 33 39 10 EA 11 $4,400.00 $48,400.00 9 3301.0101 Manhole Vacumm Testing 3301 30 EA 11 $100.00 $1,100.00 -- - - - - - 100.0 10 3305.0113 Trench Water Stop 33 05 15 EA 11 $250.00 $2,750.00 _ _ _ _ 11,11. 11 3305 0202 Imported Embedment/Backfill,CSS 33 05 10 CY 36 $80.00 $2,880.00 1..11.1 __- _ _.__. _. _ _....-. 12 3305 0116 Concrete Encasement for Utility Pipes 33 05 10 CY 175 $63.77 $11,159.75 _ _ � _ . - - 13 3305 0109 Trench Safety 33 05 10 LF 2004 $0.50 $1,002.00 14 3301.0002 Post CCTV Inspection 3301 31 LF 2004 $2.00 $4 008.00 _ _. ... _ 15 3471 0001 Traffic Control 3471, 13 MO 1 $6,000.00 $6,000.00 1111_. 1111_ 16 9999.0001 Connect to Existing 4'Manhole EA 1 $2,400.00 $2,400.00 TOTAL UNIT II:SANITARY SEWER IMPROVEMENTS $144,487.79 UNIT III:DRAINAGE IMPROVEMENTS 1 0241.3015 Remove 24'Storm Line 0241 14 LF 30 $50.00 $1,500.00 2 6241.301-7 Remove 30"-Storm Line 0241 14 LF 96 $50.00 $4,800.00 3 0241 3019 Remove 36"Storm Line 02 41 14 LF 21 $50 00 _ $1050 00 4 0241 3106 30 Storm Abandonment Plug 0241 14 EA 2 $500.00 $1,000.00 5 0241.3108 36"Storm Abandonment Plug 02 41 14 EA 2 $500.00 $1,000.00 6 0241.3401 Remove 4 Storm Junction Box 02 411 1 14 E-A 3 $800.00 $2,400.00 -- --- - - _ - �_. 7 0241 4101 Remove 10'Recessed Inlet 0241 14 EA 1 $4,575.00 $4,575.00 8 0241 4202 Remove 5'Drop Inlet 02 41 14 EA 1 $750.00 $750.00 -- - -- 9 0241 4401 Remove Headwall/SET 0241 14 EA 1 $750.00 $750.00 10 0241.0800 Remove Rip Rap 0241 14 SF 90 $3.33 $299.70 11 0241.1000 Remove Conc.Pvmt 02 41 14 SY 20 $30.00 $600.00 -- 12 3341 0201 21'RCP,Class III 34 41 10 LF 59 _ - - ._ _ . . . $50.00 _�$2,95 1 0.00 13 3341 0205 24"RCP,Class III 3441 10 LF 72 $80.00 $5,760.00 14 3341.0206 24 RCP,Class IV 34 41 10 LF 75 $80.00 $6,000.00 15 3341.0402 42 RCP,Class III 34 41 10 LF 78 $180.00 $14,040.00 -- 1010 _ _ 16 3341 0403 42'RCP,Class IN 34 41 10 LF 575 $180.00 $103,500.00 CITY OF FORT WORTH STANDARD CONSTRUCTION SPECIFICATION DOCUMENTS-DEVELOPER AWARDED PROJECTS Form Version September 1.2015 Bid Praposal_180328.s1s 00 42 43 DAP-BID PROPOSAL Pagc 2 of 2 SECTION 00 42 43 Developer Awarded Projects-PROPOSAL FORM UNIT PRICE BID Bidder's Application Revised March 28,2018 Project Item Information Bidder's Proposal Bidlist Item Specification Unit of Bid No Description Unit Price Bid Value Section No. Measure Quantity 17 3341.0409 48: RCP,Class III 3441 10 LF 801 $250.00 $200,250.00 19 3349 0002 5'Storm Junction Box 33 49 10 EA 3 $8,200.00 $24,600.00 - - - - — - — 20 3349 4113 48 SET, 1 Pipe -- 49 40 EA 1 $825.25 $825.25 21 3349.5001 10'Curb Inlet 22 3349.6001 10'Recessed Inlet 33 49 40 EA 2 $4,050.00 $8 100.00 33 4920 EA 2 $4,400.00 $8,800.00 23 3349.7001 4'Drop Inlet 33 49 20 EA 2 $4,100.00 $8,200.00 — _ _ . . 24 3305 0112 Conc Collar _ 33 05 17 ___.0 EA 1 $500.00 $500.00 _ 25 3305 0109 Trench Safe ._ _ ,_ 330510 LF 1660 $0,25 $415.0_0_ 26 13137.0104 Medium Stone Riprap,dry 31 3700 SY 91 $71.00 $6,461.00 TOTAL UNIT III:DRAINAGE IMPROVEMENTS1 $409,125.95 UNIT IV:PAVING IMPROVEMENTS 10241 1300 Remove Conc.Curb&Gutter 02 41 14 LF 375 $10.00 $3,750.00 _- ....._._. 2 3123 0101 Unclassified Excavation 31 23 16 CY 165 $68.94 $11,375.10 - - -- -- -- - - - - 3 3211 0211 6' Flexible Base,Type B GR-1 32 11 23 SY 421 $27.00 $11 367.00 _ _ _ m. 4 3213 0103 8' Conc.Pvmt. 32 13 13 SY- 421 $56.25 $23,681.25 5 3213 0301 4' Cono Sidewalk 32 13 20 SF 3320 $4.75 $15,770.00 6 3213 0506 Barrier Free Ramp,Type P-1 32 13 20 EA 2 $650.00 $1,300.00 —.. - - - 7 3216 0101 6"Conc.Curb and Gutter 32 16 13 LF 388 $5.00 $1,940.00 8 3217 0201 8"SLD Pvmt Marking HAS(W) 32 17 23 LF 65 $15.88 $1,032.20 - - - - - ,n - — -- 11 9 3217 2102 REFL Raised Marker TY 1-C 32 17 23 EA 4__ $12.50 $50.00 10 3471.0001 Traffic Control 1 3471 13 1 MO 1 $6,000.00 $600000 TOTAL UNIT IV:PAVING IMPROVEMENTS I $76,265.55 Bid Summary UNIT I:WATER IMPROVEMENTS $244,130.24 UNIT II:SANITARY SEWER IMPROVEMENTS $144,487.79 UNIT III:DRAINAGE IMPROVEMENTS $409,125.95 ------ ----- -- UNIT IV:PAVING IMPROVEMENTS $76,265.55 Total Construction Bid $874,009.53 Contractor agrees to complete WORK for FINAL ACCEPTANCE within 270 calendar days after the date when the CONTRACT commences to run as provided in the General Conditions. END OF SECTION CITY OF FORT WORTH STANDARD CONSTRUCTION SPECIFICATION DOCUMENTS-DEVELOPER AWARDED PROJECTS Forth Version September 1,2015 Bid Proposal_180328,,Is CONSENT OF OWNER SURETY COMPANY ARCHITECT TO FINAL PAYMENT CONTRACTOR SURETY AIA DOCUMENT G707 OTHER Bond No. 2223040 PROJECT: Victory of Heritage-Water, Sanitary Sewer and (name,address) Storm Drain Improvements TO(Owner) [ City of Fort Worth ] ARCHITECT'S PROJECT NO: 1000 Throckmorton Street Fort Worth,TX 76102-6312 CONTRACT FOR: Construction ] CONTRACT DATE: 1/20/2017 CONTRACTOR: PCI Construction,Inc. P.O.Box 2967 McKinney,TX 75070 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) North American Specialty Insurance Company 5200 Metcalf OPN111 Overland Park,KS 66202 , SURETY COMPANY, on bond of(here insert name and address of Contractor) PCI Construction,Inc. P.O.Box 2967 McKinney,TX 75070 , 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 1000 Throckmorton Street Fort Worth,TX 76102-6312 ,OWNER, as set forth in the said Surety Company's bond. IN WITNESS WHEREOF, the Surety Company has hereunto set its hand this 29th day of March 2018 North American Specialty Insurance Company Surety Company Attest: Signature of Authorized Representative (Seal): Debra Lee Moon 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 AIA DOCUMENT G707 CONSENT OF SURETY COMPANY TO FINAL PAYMENT APRIL 1970 EDITION AIA ONE PAGE 1970 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 New York Ave.,NW,WASHINGTON,D.C. 20006 SWISS RE CORPORATE SOLUTIONS NORTH AMERICAN SPECIALTY INSURANCE COMPANY WASHINGTON INTERNATIONAL INSURANCE COMPANY WESTPORT INSURANCE CORPORATION GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS,THAT North American Specialty Insurance Company,a corporation duly organized and existing under laws of the State of New Hampshire,and having its principal office in the City of Overland Park,Kansas and Washington International Insurance Company a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of Overland Park,Kansas,and Westport Insurance Corporation,organized under the laws of the State of Missouri,and having its principal office in the City of Overland Park,Kansas each does hereby make,constitute and appoint: SAMMY JOE MULLIS,JR.,JOHN WILLIAM NEWBY,CHERI LYNN IRBY,WILBERT RAYMOND WATSON,MICHAEL L.TULLIS,SANDRA LEE RONEY,DEBRA LEE MOON, ANDREA ROSE CRAWFORD,MARY JO ZAKRZEWSKI,JAMES B.ROGERS,JR.,TROY RUSSELL KEY AND LINDA MICHELLE STALDER JOINTLY OR SEVERALLY Its true and lawful Attomey(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: ONE HUNDRED TWENTY FIVE MILLION($125,000,000.00)DOLLARS This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of Directors of North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held on March 24,2000 and Westport Insurance Corporation by written consent of its Executive Committee dated July 18,2011. "RESOLVED,that any two of the President,any Senior Vice President,any Vice President,any Assistant Vice President, the Secretary or any Assistant Secretary be,and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named in the given Power of Attorney to execute on behalf of the Company bonds,undertakings and all contracts of surety,and that each or any of them hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is FURTHER RESOLVED,that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any certificate relating thereto by facsimile,and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be binding upon the Company when so affixed and in the future with regard to any bond,undertaking or contract of surety to which it is attached." AU�7RY'gsfi.FFoR... y/ . .\ GByrj.G Steven P.Anderson,Senior Vice President of Washington international InsuFa'54 Company SEAL &Senior Vice President of North American Specialty Insurance �4:\f•N!.!!.J.€. Company p WZ t97$ �� &Senior Vice President of Westport Insurance Corporation 7® N �l< �ya;r y'•hAM .... 'O� %sb '-a....-• ate By ..I`N ` A. , Vice of International Insurance Company �������•'• Mike AItoSenior Vie President Wt �rU!IIp�It1UI\\���\ ° umr;,rtteraii� &Senior Vice President of North American Specialty Insurance Company !€if�t3aae•' &Senior Vice President of Westport Insurance Corporation IN WITNESS WHEREOF,North American Specialty Insurance Company,Washington International Insurance Company and Westport Insurance Corporation have caused their official seals to be hereunto affixed,and these presents to be signed by their authorized officers this this 12 day of January ,20 18 North American Specialty Insurance Company Washington International Insurance Company State of Illinois Westport Insurance Corporation County of Cook Ss: On this 12 day of January 20 18,before me,a Notary Public personally appeared Steven P.Anderson , Senior Vice President of Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and Senior Vice President of Westport Insurance Corporation and Michael A.Ito Senior Vice President of Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and Senior Vice President of Westport Insurance Corporation,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. OFFICIAL SEAL " M.KENNY _ NotryPublie.Statrillinois MycCommission-xpiv-i M.Kenny,Notary Public I, Jeffrey Goldberg the duly elected Vice President and Assistant Secretary of North American Specialty Insurance Company,Washington International Insurance Company and Westport Insurance Corporation do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said North American Specialty Insurance Company,Washington International Insurance Company and Westport Insurance Corporation which is still in full force and effect. IN WITNESS WHEREOF,I have set my hand and affixed the seals of the Companies this 29th day of March 20 18 Jeffrey Goldberg,Vice President&Assistant Secretary of Washington International Insurance Company& North American Specialty Insurance Company&Vice President&Assistant Secretary of Westport Insurance Corporation North American Specialty Insurance Company Washington International Insurance Company Westport Insurance Corporation TEXAS CLAIMS INFORMATION IMPORTANT NOTICE ADVISO IMPORTANTE In order to obtain information or make a complaint: Para obtener informacion o para someter un queja: You may contact Jeffrey Goldberg,Vice President Puede comunicarse con Jeffrey Goldberg,Vice — Claims at 1-800-338-0753 President— Claims,al 1-800-338-0753 You may call Washington International Insurance Usted puede Ilamr al numero de telefono gratis de Company and/or North American Specialty Insurance Washington International Insurance Company and/or Company's and/or Westport Insurance Corporation North American Specialty Insurance Company's and/or toll-free number for information or to make a Westport Insurance Corporation para informacion o complaint at: para someter una queja al: 1-800-338-0753 1-800-338-0753 You may also write to Washington International Usted tambien puede escribir a Washington Insurance Company and/or North American Specialty International Insurance Company and/or North Insurance Company and/or Westport Insurance American Specialty Insurance Company and/or Corporation at the following address: Westport Insurance Corporation al: 1450 American Lane 1450 American Lane Suite 1100 Suite 1 100 Schaumburg,IL 60173 Schaumburg, IL 60173 You may contact the Texas Department of Insurance Puede escribir al Departmento de Seguros de Texas to obtain information on companies, coverages, para obtener informacion acerca de companias, rights or complaints at: coberturas, derechos o quejas al: 1-800-252-3439 1-800-252-3439 You may write the Texas Department of Insurance: Puede escribir al Departmento de Seguros de Texas: P.O. Box 149104 P.O. Box 149104 Austin,TX 78714-9104 Austin,TX 78714-9104 Fax: (512) 475-1771 Fax: (512)475-1771 Web: httpo//www.tdi.state.tx.us Web: hit n://www.tdi..state. x.us Email:ConsumerProtection@tdi.state.tx.us Email: ConsumerProtection@tdi.state.tx.us PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS O RECLAMOS: Should you have a dispute concerning your premium Si tiene una disputa concerniente a su prima o a un or about a claim you should first contact the reclamo, debe comunicarse con el Washington Washington International Insurance Company and/or International Insurance Company and/or North North American Specialty Insurance Company and/or American Specialty Insurance Company and/or Westport Insurance Corporation. If the dispute is not Westport Insurance Corporation primero. Si no se resolved,you may contact the Texas Department of resuelve la disputa, puede entonces comunicarse Insurance. con el Departmento de Seguros de Texas. ATTACH THIS NOTICE TO YOUR POLICY: UNA ESTE AVISO A SU POLIZA This notice is for information only and does not Este aviso es solo para proposito de infromacion y no become a part or condition of the attached se converte en parte o condicion del documento document. adjunto. CONTRACTOR'S AFFIDAVIT OF FINAL PATIENT THE STATE OF TEXAS § § MOW ALL MEN BY THESE PRESENTS: COUNTY OF Collin § BEFORE ME,the undersigned authority, on this day personally appeared John Starnes _("Affidant"),who,after being by me duly sworn,deposes,and says that he is the Controller , of PCI Construction,Inc, a Texas CoMoration (corporation,partnership,trade name) of Collin County, State of Texas (the"Contractor"),which said Contractor was awarded the contract dated_ 22nd day of December ,2016,for the construction of Victory at Heritage at_ Fort Worth,TX (the"Work"),for a total consideration of $ 1,549,129.25 Dollars to be paid to the said Contractor(the"Contract"), and that Affrdant has fiill power of authority to make this affidavit. That Peloton Land Solutions (the"Owner")has approved the final pay estimate on said Work, and that the said Contractor has fully satisfied and paid any and all claims that may be covered by Chapter 53 of the Texas Property Code and Article 5160 of the Revised Civil Statutes of the State of Texas, or any other applicable statutes or charter provisions,and that all just bills for labor and materials have been paid and discharged by said Contractor insofar as they pertain to the work in question. That in addition to any funds which may have been previously paid by the Owner,the Contractor hereby accepts the amount of$ 143,314.53`Dollars as FULL AND FINAL PAYMENT under the aforementioned Contract,and hereby waives and releases any right Affrdant and/or the Contractor may have to pursue claims of any nature against the Owner arising out of or in any manner connected with the performance of the Work and/or the Contract,including but not limited to claims of third parties that supplied material and/or labor for the Work for or through the Contractor ("Subcontractors"), as well as claims for delay, additional compensation or for recovery of liquidated damages which may have been withheld by the Owner.The Contractor shall defend,hold harmless and indemnify the Owner from any such claims of such Subcontractors.The Contractor further releases the Owner from any claim or liability arising from any act or neglect of the Owner related to or connected with the Contract. This affidavit is given pursuant to the final payment provisions of the Contract, and shall not be deemed to alter or modify the terms and provisions of said Contract. GI Co 4TH U TRW, 1 NCi By: ' (dant) J4 p, ! AlrAQS (Printed Name) SUBSCRIBED AND SWORN TO BEFORE ME,this the'24 day of (Ul AD. 2vjg By: p (Notary Public in and for the State of Texas) %Notary Public State of Texas (Printed Name of Notary) ' Notary Sea]] i -* r� My Commission$f 123944875 r,- °••FBF My Comm.Epp,September 26,20al Y commission expires: CONTRACTOR'S AFFIDAVIT OF FINAL PAYMENT THE STATE OF TEXAS § §KNOW ALL MEN BY THESE PRESENTS: COUNTY OF_Collin § BEFORE ME,the undersigned authority,on this day personally appeared David McKinley _("Affidanf),who,after being by me duly sworn,deposes,and says that he is XS Concrete a limited liability company(corporation,partnership,trade name)of_Dallas_County, State of Texas(the"Contractor"),which said Contractor was awarded the contract dated—7th—day of"),2017,for the construction of site paving at—Victory Shops @ Heritage (the"Work"),for a total consideration of $458.046.55 Dollars to be paid to the said Contractor(the"Contract"),and that Affidant has full power of authority to make this affidavit. That_XS Construction,LLC_(the"Owner'')has approved the final pay estimate on said Work, and that the said Contractor has fully satisfied and paid any and all claims that may be covered by Chapter 53 of the Texas Property Code and Article 5160 of the Revised Civil Statutes of the State of Texas, or any other applicable statutes or charter provisions,and that all just bills for labor and materials have been paid and discharged by said Contractor insofar as they pertain to the work in question. That in addition to any funds which may have been previously paid by the Owner,the Contractor hereby accepts the amount of$ 45,804.65_Dollars as FULL AND FINAL PAYMENT under the aforementioned Contract, and hereby waives and releases any right Affidant and/or the Contractor may have to pursue claims of any nature against the Owner arising out of or in any manner connected with the performance of the Work.and/or the Contract,including but not limited to claims of third parties that supplied material and/or labor for the Work for or through the Contractor ('`Subcontractors"),as well as claims for delay,additional compensation or for recovery of liquidated damages which may have been withheld by the Owner.The Contractor shall defend,hold harmless and indemnify the Owner from any such claims of such Subcontractors.The Contractor further releases the Owner from any claim or liability arising from any act or neglect of the Owner related to or connected with the Contract.This affidavit is given pursuant to the final payment provisions of the Contract,and shall not be deemed to alter or modify the terms and provisions of said Contract. By• t T-)--c,,,7Allc-K;n 1,e (Printed Name) SUBSCRIBED AND SWORN TO BEFORE ME,this the .1e day of (Y)04?6(n A.D_ ' 1 By: /'V\11"Az� � (Not bLc in and for the State of Texas) ,/ MELISSA JENKINS l Y L,��LL�S ca_ J�4 qty.P4�q _`,''` Notary Public.State of Texas (Printed NameofNotary) [Notary Se =N Ay Commission Expires Cciobei 01,2019 My commission expires: NOTICE: This document waives rights unconditionally and states that you have been paid for up those rights. It is prohibited for a person to require you to sign this document if you have not been paid the payment amount set forth below.If you have not been paid, use a conditional release form. UNCONDITIONAL WAIVER AND RELEASE ON FINAL PAYMENT" Project Victory Shops @ Heritage The signer of this document has been paid in full for all labor, services,equipment, or materials furnished to the property or to XS Construction, LLC_(person with whom signer contracted)on the property of Victory @ Heritage, LLC_(owner) located at_135&Heritage Trace Pkwy, Fort Worth,TX (location)to the following extent:_Site_(job description). The signer therefore waives and releases any mechanic's lien right, any right arising from a payment bond that complies with a state or federal statute, any common law payment bond right, any claim for payment, and any rights under any similar ordinance, rule, or statute related to claim or payment rights for persons in the signer's position. The signer warrants that the signer has already paid or will use the funds received from this final payment to promptly pay in full all of the signer's laborers, subcontractors, materialmen, and suppliers for all work, materials, equipment, or services provided for or to the above referenced project up to the date of this waiver and release. Date 3120118 KS Const ctio LLC (Company name) By (Signature) _Office Manag (Title) NOTE:Section 53281(b)(2),Texas Property Code,requires that the above form be notarized.See Chapter 121, Texas Civil Practice&Remedies Code,regarding Acknowledgments&Proofs of Written Instruments,or consult an attorney.For short acknowledgement forms that might be suitable,see Section 121.008 in Chapter 121.Click here to go there. FORT WORTH TRANSPORTATION AND PUBLIC WORKS PIPE REPORT FOR: PROJECT NAME: Victory at Heritage PROJECT NUMBER: 100485 DOE NUMBER: WATER PIPE LAID SIZE TYPE OF PIPE LF C900 6" PVC 278 0900 8" PVC 42 C900 12" PVC 2006 FIRE HYDRANTS: 5 VALVES(16" OR LARGER) PIPE ABANDONED SIZE TYPE OF PIPE LF N/A DENSITIES: yes NEW SERVICES: 2" copper 22 SEWER PIPE LAID SIZE TYPE OF PIPE LF SDR 26 8" PVC 1782 SDR 26 6" PVC 306 PIPE ABANDONED SIZE TYPE OF PIPE LF N/A DENSITIES: yes NEW SERVICES: 6" PVC 13 TRANSPORTATION AND PUBLIC WORKS The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX 76012-6311 (817)392-7941 •Fax: (817)392-7845 FORTWORTHREV:8/20/16 TRANSPORTATION AND PUBLIC WORKS PERFORMANCE EVALUATION OF CONTRACTOR 1) CONTRACTOR&PROJECT DATA Name of Contractor Project Name PCI Construction,Inc. Victory at Heritage Inspector City Project Number Matt Cain 100485 Construction Components Project Manager Q Water 21 Waste Water ❑ Storm Drainage ❑ Pavement Gopal Sahu Initial Contract Amount Project Difficulty $388,618.03 Q Simple Q Routine 0 Complex Final Contract Amount Date $355,399.65 4/4/2018 II)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 4 20 20 3 Plans on Site 5 Y 3 20 15 4 Field Supervision 15 Y 3 60 45 5 Work Performed 15 Y 3 60 45 6 Finished Product 15 Y 3 60 45 7 Job Site Safety 15 Y 3 60 45 8 Traffic Control Maintenance 15 Y 4 60 60 9 Daily Clean Up 5 Y 2 20 10 10 Citizen's Complaint Resolution 5 Y 4 20 20 11 Property Restoration 5 Y 3 20 15 12 After Hours Response 5 Y 4 20 20 13 Project Completion 5 Y 3 20 15 TOTAL ELEMENT SCORE(A) 363 BONUS POINTS(25 Maximum)(B) II1)CONTRACTOR'S RATING TOTAL SCORE(TS) 363 Maximum Score(MS)=448 or sum of applicable element score maximums which= 448 Rating([TS/MS] x 100%) 363 / 448 = 81% 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) Inspector Signature ontractor Signature Inspector's Supervisor Signature CONTRACTOR'S COMMENTS TRANSPORTATION AND PUBLIC WORKS The City of Fort Worth• 8851 Camp Bowie West Blvd. •Fort Worth,TX 76116 • (817) 392-8306 FORTWORTHREV:02'22/07 TRANSPORTATION AND PUBLIC WORKS CONTRACTOR'S EVALUATION OF CITY I)PROJECT INFORMATION Date: 4/4/2018 Name of Contractor Project Name PCI Construction, Inc. Victory at Heritage DOE Inspector Project Manager Matt Cain Gopal Sahu DOE Number Project Difficulty Type of Contract CPN:100485 0 Simple Q Routine Q Complex water Q waste water ❑ Storm Drainage ❑ Pavement j Initial Contract Amount Final Contract Amount $388,618.03 $355,399.65 I II)PERFORMANCE EVALUATION 0-Inadequate 1 -Deficient 2-Standard 3 -Good 4-Excellent ELEMENT RATING ELEMENT RATING (0-4) (0-4) INSPECTION EVALUATION PLANS&SPECIFICATIONS 1 Availability of Inspector `/ 1 Accuracy of Plans to Existing Conditions 2 Knowledge of Inspector 1/ 2 Clarity&Sufficiency of Details t/ 3 Accuracy of Measured Quantities 3 Applicability of Specifications tj 4 Display Of Professionalism 4 Accuracy of Plan Quantities 5 Citizen Complaint Resolution 1-/ PROJECT MANAGER EVALUATION 6 Performance-Setting up Valve Crews,Labs 1 Knowledge And/Or Problem Resolution ADMINISTRATION 2 Availability of Project Manager 1 Change Order Processing Time 13 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 s* The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX-76012-6311 (817) 392-7941 •Fax: (817) 392-7845 e - / \ § � R% % 0 ( / c!) ^ s § + ( \ R3 a cs § z ® z = G \ { § / C! ) Cl 0 \ / / / 7 ± k $ � / E ) 0 O 5 § 3 ® § 2 ° j L) \ 00 < > \ LR / ( � O \ / CL ID 10 w _ Cl! 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W O U z w Ix U pU� C m � } a m F O Q z w i a� O w Y L z W Q } U p ami a ry v U LL 03 6 Q Z N Q � Q N I FORT WORTH, TRANSPORTATION AND PUBLIC WORKS STATEMENT OF CONTRACT TIME STATEMENT# FINAL STATEMENT# 1 CPN# 1 100485 NAME OF PROJECT: Victory at Heritage Contractor PCI YEAR:j 2018 PROJECT NO.: FINAL INSPECTION DATE 7-Mar-18 WTR-59601-0600430-100485-001580 1 WD CD SWR-59607-0700430-100485-001380 1CONTRACTTIME 270 X PERIOD FROM: 1 3/16/2018 TO: 1 3/31/2018 MID - Month DEVELOPMENT (N,'/N)IY WORK ORDER EFFECTIVE: 2/20/2017 1 BEG( /n) n MID /n) y 145.6% LIP YR(y/n) DAY OF MONTH DAYS REASON FOR DAY OF MONTH DAYS REASON FOR CHARGED DAYS CREDITED CHARGED DAYS CREDITED 1 Fri 16 Fri 1 2 Sat 17 Sat 1 3 Sun 18 Sun 1 4 Mon 19 Mon 1 5 Tue 20 Tue 0 na 6 Wed 21 Wed 0 na 7 Thu 22 Thu 0 na 8 Fri 23 Fri 0 na 9 Sat 24 Sat 0 na 10 Sun 25 Sun 0 na 11 Mon 26 Mon 0 na 12 Tue 27 Tue 0 na 13 Wed 28 Wed 0 na 14 Thu 29 Thu 0 na 15 Fri 30 Fri 0 na 31 Sat 0 na NA Wkn&Hol Wea Utl Oth Not Applicable SAT,SUN,and WEATHER UTILITIES OTHERS DAYS TOTAL DAYS HOLIDAYS RELOCATE CHARGED THIS PERIOD 0 0 0 0 4 4 PREVIOUS PERIOD 0 389 389 TOTAL TO DATE 0 0 0 0 393 393 REMARKS: Final inspection was held on 3/7/18. Punch list was complete on 3/19/18. -"to Signature: : �7 �`�� Signature (Print Name) (Print Name) Matt Cain J DATE CONTRACTOR DATE �� e/ ZSPECTOR