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Home My WebLink AboutContract 49550-FP3 ! City Secretary 49550 -FP3 Contract No. FoRTWORTH, Date Received Oct 4,2018 6-6 66 ql�s NOTICE OF PROJECT COMPLETION (Developer Projects) The Transportation and Public Works Department upon the recommendation of the Project Manager has accepted the following project as cornplete: Project Name: REVELSTOKE, SECTION 1A i City Project No.: 100965 Improvement Type(s): Water ® Sewer Original Contract Price: $819,676.75 Amount of Approved Change Order(s): $25,417.60 Revised Contract Amount: $845,094.35 Total Cost of Work Complete: $845,094.35 2�6W&4Nkl9 �1 Se 27 2018 Kevin Gemenkom(Sep 27,20181 P s Contractor Date PCI Construction Inc. Title Executive VP of Operations Company Name ' Zb&ir`Sa&a&d;ts°.. Se 28 2018 Mbert Saman(cgo(Sep 28,20 ) p s Prinspector Date Fred Mia(oa 2, l$) Oct 2,2018 Projektan ger Date 7ahra Ct�6fa(ed `7anie Scarlett Morales(Oct 2,2018) Oct 2,2018 CFA Manager Date Safsafr✓'4�anry Oct 4 2018 Susan Al-is(Oct 4,2018) i Asst. City Manager Date RECEIVED OFFICIAL RECORD Page 1 of 2 9 2018 CITY SECRETARY Cl C SORT woo ECHF7AR �.WORTH,TX `ice of Project Completion Project Name: REVELSTOKE, SECTION 1A City Project No.: 100965 City's Attachments Final Pay Estimate Change Order(s): x❑ Yes ❑ N/A Pipe Report: ® Yes ❑ NIA Contractor's Attachments Affidavit of Bills Paid Consent of Surety ii Statement of Contract Time a f` Contract Time: 102 CD Days Charged: 334 Work Start Date: 10/9/2017 Work Complete Date: 9/7/2018 i i { 9 i R I J �J f Page 2 of 2 City Project Numbers 100965 DOE Number 0965 Contract Name REVELSTOKE,SECTION 1A Estimate Number I Contract Limits Payment Number I Project Type WATER&SEWER For Period Ending 9/13/2018 Y Project Funding Project Manager NA City Secretary Contract Number Inspectors OWEN / SLATEN Contract Date �I Contractor POWELL CONSTRUCTION Contract Time 102 CD IIII P 0 BOX 2967 Days Charged to Date 334 CD MCKINNEY, TX 75070 Contract is .000000 Complete i CITY OF FORT WORTH SUMMARY OF CHARGES Line fund Account Center Amount Gross Retainage Net Funded i - - - -- C I , f Total Cost of Work Completed $845,094.35 �I I Less %Retained $0.00 Net Earned $845,094.35 Earned This Period $845,094.35 Retainage This Period $0.00 Less Liquidated Damages 0 Days @ $0.00 /Day $0.00 I LessPavement Deficiency $0.00 r Less Penalty $0.00 i Less Previous Payment $0.00 Plus Material on Hand Less 15% $0.00 Balance Due This Payment $845,094.35 I. 'I Friday,September 14,2018 Page 5 of 5 �I n it Il r FORTWORTH CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name REVELSTOKE,SECTION IA Contract Limits Project Type WATER&SEWER City Project Numbers 100965 DOE Number 0965 Estimate Number I Payment Number 1 For Period Ending 9/13/2018 CD City Secretary Contract Number Contract Time 1001) Contract Date Days Charged to Date 334 Project Manager NA Contract is 100.00 Complete Contractor POWELL CONSTRUCTION P O BOX 2967 MCKINNEY, TX 75070 Inspectors OWEN / SLATEN Ii I 1 1 l r Friday,September 14,2018 Page 1 of 5 k City Project Numbers 100965 DOE Number 0965 Contract Name REVELSTOKE,SECTION I Estimate Number I Contract Limits Payment Number I Project Type WATER&SEWER For Period Ending 9/13/2018 Project Funding WATER Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total --------------------------------------- 1 4"WATER PIPE CO#1 75 LF $13.80 $1,035.00 75 $1,035.00 2 8"WATER PIPE C091 7241 LF $20.50 $148,440.50 7241 $148,440.50 3 8"DIP WATER 425 LF $32.50 $13,812.50 425 $13,812.50 4 12"WATER PIPE 1239 LF $31.40 $38,904.60 1239 $38,904.60 5 12"DIP WATER 160 LF $53.90 $8,624.00 160 $8,624.00 6 CONCRETE ENCASEMENT FOR UTILITY PIPES 2.4 CY $226.00 $542.40 2.4 $542.40 7 4"GATE VALVE 1 EA $757.00 $757.00 I $757.00 8 8"GATE VALVE 26 EA $1,254.00 $32,604.00 26 $32,604.00 9 12"GATE VALVE 8 EA $2,141.00 $17,128.00 8 $17,128.00 10 FIRE HYDRANT 12 EA $4,844.00 $58,1.28.00 12 $58,128.00 11 8"X 4"TAPPING SLEEVE&VALVE 1 EA $2,433.00 $2,433.00 1 $2,433.00 12 DUCTILE IRON WATER FITTINGS 3.57 TN $13,063.00 $46,634.91 3.57 $46,634.91 W/RESTRAINT 13 1"WATER SERVICE 115 EA $677.00 $77,855.00 115 $77,855.00 14 CONNECTION TO EXISTING 4"-12"WATER 4 EA $1,610.00 $6,440.00 4 $6,440.00 MAIN 15 TRENCH SAFETY CO#1 9140 LF $0.10 $914.00 9140 $914.00 16 2"IRRIGATION SERVICE CO#1 3 EA $1,979.00 $5,937.00 3 $5,937.00 17 2"WATER PIPE CO#1 24 LF $11.40 $273.60 24 $273.60 18 3"METER VAULT CO#1 I EA $16,778.00 $16,778.00 1 $16,778.00 19 BONDS FOR ALL UTILITY CO#1 1 LS $1,430.00 $1,430.00 1 $1,430.00 Sub-Total of Previous Unit $478,671.51 $478,671.51 SEWER Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total 1 12"SEWER PIPE 807 LF $31.00 $25,017.00 807 $25,017.00 2 12"SEWER PIPE 458 LF $31.00 $14,198.00 458 $14,198.00 3 8"SEWER PIPE 2369 LF $25.30 $59,935.70 2369 $59,935.70 4 8"SEWER PIPE 1892 LF $25.20 $47,678.40 1892 $47,678.40 5 REMOVE 8"SEWER LINE 10 LF $37.00 $370.00 10 $370.00 6 4"SEWER SERVICE 115 EA $813.00 $93,495.00 115 $93,495.00 Friday,September 14,2018 Page 2 of 5 L' i City Project Numbers 100965 DOE Number 0965 Contract Name REVELSTOKE,SECTION IA Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 9/13/2018 Project Funding 7 CONCRETE ENCASEMENT FOR UTILITY PIPES 34.8 CY $226.00 $7,864.80 34.8 $7,864.80 8 4'MANHOLE 17 EA $2,610.00 $44,370.00 17 $44,370.00 9 4'DROP MANHOLE 1 EA $5,668.00 $5,668.00 1 $5,668.00 10 4'MANHOLE W/HYDRAULIC SLIDE 2 EA $5,108.00 $10,216.00 2 $10,216.00 11 4'EXTRA DEPTH MANHOLE 64.68 VF $158.00 $10,219.44 64.68 $10,219.44 12 MANHOLE ADJUSTMENT 5 EA $2,458.00 $12,290.00 5 $12,290.00 13 EPDXY MANHOLE LINER 11.7 VF $283.00 $3,311.10 11.7 $3,311.10 14 CONCRETE COLLAR 1 EA $316.00 $316.00 1 $316.00 15 CONNECTION TO EXISTING PIPE 6 EA $1,384.00 $8,304.00 6 $8,304.00 16 CONNECTION TO EXISTING MANHOLE I EA $3,644.00 $3,644.00 1 $3,644.00 17 TRENCH SAFETY 5526 LF $0.60 $3,315.60 5526 $3,315.60 1S POST CCTV INSPECTION 5526 LF $2.30 $12,709.80 5526 $12,709.80 19 MANHOLE VACUUM TESTING 20 EA $175.00 $3,500.00 20 $3,500.00 -------------------------------------- Sub-Total of Previous Unit $366,422.84 $366,422.84 Friday,September 14,2018 Page 3 of 5 City Project Numbers 100965 DOE Number 0965 Contract Name REVFLSTOKE,SECTION IA Estimate Number I Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 9/13/2018 Project Funding Contract Information Summary Original Contract Amount $819,676.75 Change Orders Change Order Number 1 $25,417.60 Total Contract Price $845,094.35 Total Cost of Work Completed $845,094.35 Less %Retained $0.00 Net Earned $845,094.35 Earned This Period $845,094.35 Retainage This Period $0.00 Less Liquidated Damages Days rJ !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 $845,094.35 Friday,September 14,2018 Page 4 of 5 DEVELOPER-AWARDED-PROJECT CHANGE ORDER PROJECT NAME: REVELSTOKE SECTION IA CONTRACT: PAVING a unLlnCHANGEes ORDER No: CFA# 2017-068CITY PARTICIPATION: ttD CITY PROJECT# 100966 DOE# NIA WATER PROJECT# 56000.OGOD43D•100960.001660 co 14t SEWER PROJECT# 6G00a-0700430.100966.0013A00 FILE# X-24371 INSPECTOR: Phone No: PROJECT MANAGER: Phone No: CONTRACT UNIT WATER SEWER PAVING DRAINAGE STREETLIGHTS CONTRACT Developer 4':.:;$ Developer CDovolopor Developer Developer DAYS Cost Cost Cost1.i i Cost �Y.'»f.__. CN4_Cost ORIGINAL CONTRACT $453,153.91 $36G,422.84 $1,427,de].6a _ 61,66],610.40 So.00 EXTRAS 70 DATE -1 So.00 $0.00 � � $0.00 CREDITS TO DATE 'A, $0.00 So.00 so.00 CONTRACTTODATE $463,263.91 $366,422.84 ' �`9i $1,427.60].66 CC~ 31,943,619.40 i0$ 30.00 102 AMOUNT OF PROP.CHANGE ORDER $26,417.60 t` 0 REVISED-CONTRACT AMOUNT $478,671.51 r+'?, $366,422.84 $1,427,603.66 :':O.G: $1,66],618.40 fi.9>t So.eo 102 TOTAL REVISED CONTRACT AMOUNT PER UNIT $470 671.61 $366,422.84 $1,427,503.65 $1,663,619.40 $D.00 REVISED COST SHARE Dev.Cost• $3,836,117.30 Ccst. $000 TOTAL REVISED CONTRACT $3,636,117.30 Revised:10-12-2011 Page 1 j You are directed to make the lollowing changes in the contract documents: Unit l-Water Improvements i CIN 810 ITEM PAY ITEM f7 QUANTITY UNIT ITEM DESCRIPTION UNIT PRICE TOTAL 1 3311.OD4155. LF 4"WalarPipe S 13.80 $ 759.00 �\ 2 3311.0241 7,206. LF 6"Walef Pipe S 20.50 S 147,723.OD li 3 3371.0251 425. LF a"DIPWatcr S 32.50 S 13,812.50 4 3311.0441 1,239. LF 12"Watorpipa -S-31.40 S 30,004.60 5 3311.0451 160. LF 12"DIPWater S 53.90 S 8,624.00 6 3305.0116 2.4 CY Cmmrcle Encasement for UIIOIy Plpos $ 226.00 $ 542.40 7 3312.3001 1. EA 4"Gale Volvo $ 757.001S 757.00 0 3312.3003 26. EA 8"Gale Valve $ 7,254.00 $ 32,604.00 e 3342.3005 B. EA 12'Gale Valve S 2,141.00 S 17,120.01) 10 3312.0001 12. EA Filo Hydrant 5 4,844.00 S 58,128.00 11 3312.4003 1.1 EA 8"x 4"Topping Sieave,&Valva $ 2,433.00 S 2,433.10 '. 12 3317.0001 3.57 TON Dudilo iron Water Fillings v4 Restraint S 13,053.00 S 46,634.01 13 33122003115. EA 1'Water SeMce S 677.00 5 77,855.00 14 33120117 4. EA Connection to Existing 4.12"Water Alain 3 1,610.01) S 6,440.00 q 15 3305.0109 9,085, LF Trench Safety $ 0.1D $ 008.50 16 9889.0038 3. EA- 2"IrrtaBon SOmlce-0041- 9 1 1 $ 1,979.00 $ 5,937.00 17 9999.0039 24. LF 2"Waiar Pipe I-CO 41-1 5 11.40 5 273.60 r. t 73311.0241 35. LF a"Wolar Pip.I-CO 01-1 $ 20.5D 3 717.50 1,f A9- 3311.0041 20. LF 4"Water Pipe I-CO 41-1 5 13.80-T-27F.-06 3312.2801 1. FA 3"Water Motor&Vault l-CO 41-1 S 16,776.DO $ 16,778.00 a 3305.0109 65. LF hooch Safety I-CO 41-1 $ 0.10 $ 5.50 9999.0024 1. LS Bonds for all Utlllly lmprovemonis I-CO 111-1 S 1,430.00 3 1.430.00 TOTAL Unit i-Water improvements S 478,677.51 �. Revised:10-12.2011 Page 1 REASONS FOR CHANGE ORDER Wafer connections and oppudenances at the school silo have been adjusted per the request of NISO.Connection bcations ere along Sponi<h Needle On-end Bolle Pra no Trac. NO CITY FUNDS INVOLVED IN THIS CONTRACT.DEVELOPER IS RESPONSIBLE FOR 100%OF THE CHANGE ORDER COST AND NO REIMBURSEMENT FROM THE CITY WILL BE SOUGHT BY THE DEVELOPER. RECOMMEN APPROVED: APPROVED: i Jacoi enng Group,Inc. D.R.Horton-Texas,LT Powell Construction,Inc. —y Name: Erik HPITT Name: Mark Allen Name: Eric M.Lindberg Title:ProJI nager Title: PSSKfN1r JKe PRE41 aL�T Title: CIO Revised:10.12-2011 Paget u I i a 1 s u `tr p f k I n FORTWORTH TRANSPORTATION AND PUBLIC WORKS PIPE REPORT FOR: PROJECT NAME: Revelstoke Section IA PROJECT NUMBER: 100965 DOE NUMBER: N/A WATER PIPE LAID SIZE TYPE OF PIPE LF 4" PVC 55 8" PVC 7206 8" DIP 425 12" PVC 1239 12" DIP 160 FIRE HYDRANTS: 12 VALVES(16"OR LARGER) N/A PIPE ABANDONED SIZE TYPE OF PIPE LF DENSITIES: All Passed NEW SERVICES: 1" Copper 2850 SEWER PIPE LAID SIZE TYPE OF PIPE LF 12" 1265 8" 4261 PIPE ABANDONED SIZE TYPE OF PIPE LF DENSITIES: All Passed NEW SERVICES: 4" PVC 2850 'TRANSPORTATION AND PUBLIC WORKS nAm The City of Fort Worth•1000 Throckmorton Strect•Fort Worth,TY 76012-6311 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 John Starnes _("Affidant"),who,after being by me duly sworn,deposes,and says that he is the Controller ,of PCI Construction, Inc. a Texas Corporation (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 Revelstoke 1A at Fort Worth, TX (the "Work"), for a total consideration of Two million three hundred eighty three thousand one hundred ninety-six& 15/100($2,383,196.15) Dollars to be paid to the said Contractor(the"Contract"),and that Affidant has full power of authority to make this affidavit. That Peloton Land Solutions (the "Owner") has approved the final pay estimate on said Work, and that the said Contractor has fully satisfied and paid any and all claims that may be covered by Chapter 53 of the Texas Property Code and Article 5160 of the Revised Civil Statutes of the State of Texas, or any other applicable statutes or charter provisions, and that all just bills for labor and materials have been paid and discharged by said Contractor insofar as they pertain to the work in question. That in addition to any funds which may have been previously paid by the Owner, the Contractor hereby accepts the amount of$_Two hundred forty one thousand six hundred thirty one & 08/100 ($241,631.08)_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: (Printed Name) SUBSCRIBED AND SWORN TO BEFORE ME,this the day of By. 1 r (Notary Public in and for the State of Texas) ;Y < DREE M,l iV , (Printed Name of Notary) [Notary Seal] °` e, is (�_ ":i�loiary Public Si ate of T�:,u My commission expires: ' L l� {i -k� t. .L:i ly . a• ,.. f My commission 1 123E?44875 'rr My Comm.E;p,S.pLmbe;20,20110 ;7 n V W N A1 W N -N+ O m m V m m A W N O m Ol V m m A W N m O O Z A A m Np m --1 -I 0 0 p -` Ul OD A � A W OD ^ j m m 7 O O p N N 3 O @ 0 7 p X _ N _ c a N N O d o x p Q O m ni of O O N ti °= A � � o � A m m0 0 0 y m m < m 3 3 3 p p p v m m m m m o v o m m m p O W N .my. m m N N A .Z�1 '� O, c) m^ T a m m m m m m' m m m m m m o o -n m m < H � � v ➢ D m 6 m � o S-�I � � m A O � � m < w a m� Rm° an � An � A WS NmZ TS � oco O m m a O N W N O � m m m � d k X O N m m pj N n p m O N ' O 3 A -A+ W T T T O m O X N N N i m m f N = N 'D 'O A m Q 0 N I=O n• o O o N O D VI m c o C1 f'1 w rn chz m W ti ^y m m 2 a N O m m m m m m 'n ➢ A D D A 'rn omi d w omi omi ami omi ami - - _ - - z m n j3 d ,'� -� m W A m O N W N m A N -' A O m m N V N m V S. 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N O p o p 0 0 o p o p p p p p 0 0 o O p o p o O o 0 0 0 0 0 0 0 0 0 '0 0 0 0 0 o 0 o 0 o a o 0 o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o g o 0 0 0 0 0 0 n 0 0 o e h 0 0 0 0 0 0 0 0 0 0 o a o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o e > 0 0 0 0 0 0 0 0 a 0 0 rt CONSENT OF CONTRACTOR SURETY COMPANY ARCHITECT TO FINAL PAYMENT SUBCONTRACTOR SURETY AIA DOCUMENT G707(Modified) OTHER Bond No. 2260587 PROJECT: Revelstoke,Section 1A-Water,Sanitary Sewer and Storm Drain Improvements (name,address) TO(Contractor) [ City of Fort Worth ] ARCHITECT'S PROJECT NO: 1000 Throckmorton Street Fort Worth,TX 76102-6312 CONTRACT FOR: Construction [ ] CONTRACT DATE: 8/1/2017 SUBCONTRACTOR: PCI Construction,Inc. P.O.Box 2967 McKinney,TX 75070 In accordance with the provisions of the Contract between the Contractor and the Subcontractor 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 Subcontractor) PCI Construction,Inc. P.O.Box 2967 McKinnev,TX 75070 , SUBCONTRACTOR, hereby approves of the final payment to the Subcontractor,and agrees that final payment to the Subcontractor shall not relieve the Surety Company of any of its obligations to (here insert name and address of Contractor) City of Fort Worth 1000 Throckmorton Street Fort Worth,TX 76102-6312 ,CONTRACTOR, as set forth in the said Surety Company's bond. IN WITNESS WHEREOF, the Surety Company has hereunto set its hand this 17th day of September 12018 North American Specialty Insurance Company Surety Company Signature of Authorized Representative Witness: (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 htsurance 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 CRAWPORD,MARY JO ZAKRZEWSKI,JAMES B.ROGERS,JR,TROY RUSSELL KEY,LINDA MICHELLE STALDER AND CHRISTOPHER CARL SUNDBERG 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 o£ ONE HUNDRED TWENTY FIVE MILLION(S 125,000,000.00)DOLLARS This Power of Attorney is granted and is signed by facsimile under and by(lie 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 shalt 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." s�Qre 114, �i aBy 0 e`�'"siPo`. yy, 11Ec y GpPpOA,{j Gyyy Steven n erson,Senior ice President o 1 as ng op international nsuranea Company tr' SEAL0.:� � `5�L &Senior Vice President of North American Specialty insurance Company WS 1973 u,:rn &Senior Vice President of Westport Insurance Corporation o j i hAMPs d Mike A.Ito,Senior Vice President of washington International Insurance Company • ' &Senior Vice President of North American Specially Insurance Company rfHtI &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 20th day of August ,20 18 , North American Specialty Insurance Company Washington International Insurance Company ° State of Illinois Westport Insurance Corporation County of Cook ss: On this 20th day of August 201 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 q I 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 Notary Dublic-State of IAinms Myc roma an pact M.Kenny,Notary Public I 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. e IN WITNESS WHEREOF,I have set my hand and affixed the seals of the Companies this 17th_day of September ,2018 Jeffrey Goldberg,Vice President&Assistant Secrelan•or Washington International Insurance Company North American Specialty Insurance Company&Vice President&Assistant Secretary of Westport Insurance Corporation z 9 "l North American Specialty Insurance Company Washington International Insurance Company Westport Insurance Corporation TEXAS CLAIMS INFORMATION IMPORTANT NOTICF ADVISO IMPORTANTF 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 1100 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: http://www.trii.statp.tx.ii,; Web: httl2://www.tdi.statp.tx-ijs 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 C Washington International.lnsurance 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. i I; 4 Greensheet for Revelstoke, ^ .�. .-_ Section 1 A CPN#100965 WS Adobe Sign Document History 10/08/2018 Created: 09/14/2018 By: Shameka.Kennedy@fortworthtexas.gov - -- - Status: Signed Transaction ID: CBJCHBCAABAADJ-380rIDtZoA2czKtnQtEjeNPwGZeb_ "Greensheet for Revelstoke, Section 1A CPN#100965 WS" Hist o ry Document created by Shameka.Kennedy@fortworthtexas.gov 09/14/2018-8:58:08 AM CDT-IP address:209.194.29.100 ;. Document emailed to Kevin Gerstenkorn Oasonfuhr@pciconstruction.com)for signature 09/14/2018-9:05:55 AM CDT Document viewed by Kevin Gerstenkorn Oasonfuhr@pciconstruction.com) 09/14/2018-10:01:40 AM CDT-IP address: 107.77.201.186 Chi Kevin Gerstenkorn Qasonfuhr@pciconstruction.com) uploaded the following supporting documents: C, File Attachment 1 (i File Attachment 2 09/27/2018-4:03:39 PM CDT b . Document e-signed by Kevin Gerstenkorn Oasonfuhr@pciconstruction.com) Signature Date:09/27/2018-4:03:39 PM CDT-Time Source:server-IP address: 108.178.72.146 Document emailed to Albert Samaniego (albeit.samaniego@fortworthtexas.gov)for signature 09/27/2018-4:03:41 PM CDT °u Document viewed by Albert Samaniego (albeit.samaniego@fortworthtexas.gov) 09/28/2018-7:33:09 AM CDT-IP address: 174.207.1.121 { i" Document e-signed by Albert Samaniego (albert.samaniego@fortworthtexas.gov) J Signature Date:09/28/2018-7:33:38 AM CDT-Time Source:server-IP address:174.207.1.121 C Document emailed to Joe Rogers Qoseph.rogers@fortworthtexas.gov)for approval 09/28/2018-7:33:40 AM CDT FORT WORTH, Adobe Sign Document viewed by Joe Rogers (Joseph.rogers@fortworthtexas.gov) 09/28/2018-7:35:34 AM CDT-IP address:209.194.29.100 . Document approved by Joe Rogers Qoseph.rogers@fortworthtexas.gov) Approval Date:09/28/2018-7:35:53 AM CDT-Time Source:server-IP address:209.194.29.100 Document emailed to Fred Ehia (freidoon.ehia@fortworthtexas.gov)for signature 09/28/2018-7:35:55 AM CDT Document viewed by Fred Ehia (freidoon.ehia@fortworthtexas.gov) 10/02/2018-10:02:01 AM CDT-IP address:209.194.29.100 Jy, Document e-signed by Fred Ehia (freidoon.ehia@fortworthtexas.gov) Signature Date:10/02/2018-10:06:38 AM CDT-Time Source:server-IP address:209.194.29.100 C' Document emailed to Janie Scarlett Morales (Janie.morales@fortworthtexas.gov)for signature 10/02/2018-10:06:41 AM CDT E Document viewed by Janie Scarlett Morales Oanie.morales@fortworthtexas.gov) 10/02/2018-11:37:26 AM CDT-IP address:209.194.29.100 O. Document e-signed by Janie Scarlett Morales (Janie.morales@fortworthtexas.gov) Signature Date: 10/02/2018-11:38:35 AM CDT-Time Source:server-IP address:209.194.29.100 Document emailed to Susan Alanis(susan.alanis@fortworthtexas.gov)for signature 10/02/2018-11:38:37 AM CDT )L Document viewed by Susan Alanis (susan.alanis@fortworthtexas.gov) 10/04/2018-9:47:43 AM CDT-IP address:209.194.29.100 Document e-signed by Susan Alanis (susan.alanis@fortworthtexas.gov) Signature Date:10/04/2018-9:48:00 AM CDT-Time Source:server-IP address:209.194.29.100 E_4' Document emailed to Allison Tidwell (cso_finalpay@fortworthtexas.gov)for filling 10/04/2018-9:48:02 AM CDT i y Document viewed by Allison Tidwell (cso_finalpay@fortworthtexas.gov) 10/04/2018-4:18:33 PM CDT-IP address:209.194.29.100 bo Form filled by Allison Tidwell (cso_finalpay@fortworthtexas.gov) Form filling Date: 10/04/2018-4:19:17 PM CDT-Time Source:server-IP address:209.194.29.100 C; Document emailed to Trudy Brotherton (therese.brotherton@fortworthtexas.gov)for delivery 10/04/2018-4:19:19 PM CDT 5 Document viewed by Trudy Brotherton (therese.brotherton@fortworthtexas.gov) 10/05/2018-6:58:09 AM CDT-IP address:209.194.29.100 Adobe Sign Document receipt acknowledged by Trudy Brotherton (therese.brotherton@fortworthtexas.gov) Receipt Acknowledgement Date:10/05/2018-6:58:26 AM CDT-Time Source:server-IP address:209.194.29.100 Cy Document emailed to JAGeho Qulie.geho@fortworthtexas.gov)for delivery 10/05/2018-6:58:27 AM CDT `5 Document viewed by JAGeho Qulie.geho@fortworthtexas.gov) 10/05/2018-7:49:08 AM CDT-IP address:209.194.29.100 60Document receipt acknowledged by JAGeho Oulie.geho@fortworthtexas.gov) Receipt Acknowledgement Date:10/05/2018-7:49:27 AM CDT-Time Source:server-IP address:209.194.29.100 C> Document emailed to Monica De Anda (monica.deanda@fortworthtexas.gov)for delivery 10/05/2018-7:49:28 AM CDT Document viewed by Monica De Anda (monica.deanda@fortworthtexas.gov) 10/08/2018-2:20:04 PM CDT-IP address:209.194.29.100 ba Document receipt acknowledged by Monica De Anda (monica.deanda@fortworthtexas.gov) Receipt Acknowledgement Date:10/08/2018-2:20:21 PM CDT-Time Source:server-IP address:209.194.29.100 P-4 Document emailed to Sylvia Kelley (tpwcfafiscal@fortworthtexas.gov)for delivery 10/08/2018-2:20:22 PM CDT Document viewed by Sylvia Kelley(tpwcfafiscal@fortworthtexas.gov) 10/08/2018-2:41:39 PM CDT-IP address:209.194.29.100 6a Document receipt acknowledged by Sylvia Kelley(tpwcfafiscal@fortworthtexas.gov) Receipt Acknowledgement Date:10/08/2018-2:41:52 PM CDT-Time Source:server-IP address:209.194.29.100 d Signed document emailed to Monica De Anda (monica.deanda@fortworthtexas.gov), Joe Rogers Qoseph.rogers@fortworthtexas.gov), Janie Scarlett Morales (Janie.morales@fortworthtexas.gov), Kevin Gerstenkorn Qasonfuhr@pciconstruction.com), and 8 more 10/08/2018-2:41:52 PM CDT FoxJy Adobe Sign