Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Contract 48254-FP1
FoRTWORTH CSC No. 48254-FP1 WATER DEPARTMENT ENGINEERING AND FISCAL SERVICES �� jo0 � .. J o cb?Q 1 NOTICE OF PROJECT COMPLETION DOE. No: N/A Regarding contract 48254 for Sanitary Sewer Rehabilitation Contract=OV(84) as required by the Water Department as approved by City Council on 8/16/16 through M&C C-27876 the Director of the Water Department, upon the recommendation of the Sr. Capital Projects Officer, Capital Projects Delivery,Water Department,has accepted the project as complete. Original Contract Prices: $3,534,032.50 Amount of Approved Change Orders: $458,408.50 Ns 3 Revised Contract Amount: $3,992,441.00 Total Cost Work Completed: $3,506,946.00 Less Deductions: Liquidated Damages: Days @$630.00/Day Other Deductions(see comments): Total Deduction Amount: $0.00 Total Cost Work Completed: $3,506,946.00 Less Previous Payments: $3,331,598.72 Final Payment Due $175,347.28 2- tr12- Recommended for Acceptance Date Assistant Director, Water Department Chz--I toLhe z h` Ww- Aug 2021 Christopher H rder(Aug 5,202111:40 CDT) g Accepted Date Director, Water Department DaB�urghffg4CDT) Aug 7, 2021 City Manager Date OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Project Name: Sanitary Sewer Rehabilitation Contract=OV (84) DOE. Ns: N/A Comments: Non-PO voucher retainage only 5- 1? — t oo ?(c C.s Z'8 q a3 City Project Numbers 01503 DOE Number 6592 Contract Name Sanitary Sewer Rehabilitation Contract:XXXOV(84) Estimate Number 12 Contract Limits in the Carter Riverside Neighborhood Payment Number 12 Project Type Pavins For Period Ending 4/21/2021 Project Funding Project Manager Sauceda City Secretary Contract Number 48254 Inspectors Johnson / Die Contract Date 8/16/2016 Contractor CIRCLE C CONSTRUCTION COMPANY Contract Time 1405 CD PO BOX 40328 Days Charged to Date 1395 CD FORT WORTH, TX 76140 Contract is .000000 Complete CITY OF FORT WORTH SUMMARY OF CHARGES Line Fund Account Center Amount Gross Retainage Net Funded - -------- --------- -------- ----------- - 1 59601-001503 $3,534,032.50 $0.00 $+147,139.13 $147,139.13 39408-C01503 564 194 00 �0 00 S+ 28.20R 15 29?'09 15 Total Cost of Work Completed $3 506,946.00 Less 0 %Retained SO.00 Net Earned 53,506,946.00 Earned This Period $175,347.28 Retainage This Period $0.00 Less Liquidated Damages 0 Days @ $0.00 /Day SO.00 LessPavement Deficiency SO.00 Less Penalty 50.00 Less Previous Payment 53,331,598.72 Plus Material on Hand Less 15% 50.00 Balance Due This Payment $17 5,347.28 Friday,April 23,2021 Page 7 of 7 FoRTWORTH CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name Sanitary Sewer Rehabilitation Contract:XXXOV(84) Contract Limits in the Carter Riverside Neighborhood Project Type Sewer City Project Numbers 01503 DOE Number 6592 Estimate Number 12 Payment Number 12 For Period Ending 4/21/2021 CD City Secretary Contract Number 48254 Contract Time 1406D Contract Date 8/16/2016 Days Charged to Date 1395 Project Manager Sauceda Contract is 90.000 Complete Contractor CIRCLE C CONSTRUCTION COMPANY PO BOX 40328 FORT WORTH, TX 76140 Inspectors Johnson / Die Friday,April 23,2021 Page 1 of 7 City Project Numbers 01503 DOE Number 6592 Contract Name Sanitary Sewer Rehabilitation Contract:XXXOV(84) Estimate Number 12 Contract Limits in the Carter Riverside Neighborhood Payment Number 12 Project Type Sewer For Period Ending 4/21/2021 Project Funding Sanitary Sewer&Paving Base Bid Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total --------------------------------------- 1 18"Sewer Pipe(CLSM)-Pressure Rat 855 LF $135.00 $115,425.00 852 $115,020.00 2 16"DIP Sewer(CLSM)-Pressure Rate 500 LF $180.00 $90,000.00 507 $91,260.00 3 16"Sewer Pipe(CLSM)Pressure Rated 4675 LF $120.00 $561,000.00 4689 $562,680.00 4 10"Sewer Pipe 690 LF $53.00 $36,570.00 610 $32,330.00 5 10"CIPP 540 LF $53.00 $28,620.00 620 $32,860.00 6 8"HDPE Sewer Pipe 45 LF $42.00 $1,890.00 7 8"Sewer Pipe 6273 LF $42.00 $263,466.00 6273 $263,466.00 8 8"Pipe Enlargement 3920 LF $42.00 $164,640.00 3482 $146,244.00 9 8" Point Repair(Sag Adjustment) 100 LF $100.00 $10,000.00 100 $10,000.00 10 Pre-CCTV Inspection 8405 LF $5.00 $42,025.00 12100 $60,500.00 11 Post-CCTV Inspection 13660 LF $3.00 $40,980.00 16660 $49,980.00 12 Trench Safety 10370 LF $2.00 $20,740.00 11611 $23,222.00 13 Concrete Collar 53 EA $350.00 $18,550.00 42 $14,700.00 14 4'Manhole 54 EA $3,200.00 $172,800.00 54 $172,800.00 15 4'Drop Manhole 11 EA $4,500.00 $49,500.00 14 $63,000.00 16 4'Shallow Manhole 6 EA $3,200.00 $19,200.00 1 $3,200.00 17 4'Double Drop Manhole(New) 1 EA $5,500.00 $5,500.00 18 4'Extra Depth Manhole 115 VF $150.00 $17,250.00 111.4 $16,710.00 19 Epoxy Manhole Liner 0 VF $185.00 $0.00 20 Manhole Vacuum Testing 53 EA $100.00 $5,300.00 10 $1,000.00 21 Remove 4'Sewer Manhole 49 EA $800.00 $39,200.00 49 $39,200.00 22 Sanitary Line Grouting 30 CY $150.00 $4,500.00 35 $5,250.00 23 10 or 12"Sewer Abandonment Plug 5 EA $1,000.00 $5,000.00 7 $7,000.00 24 8"Sewer Abandonment Plug 2 EA $800.00 $1,600.00 2 $1,600.00 25 6"Sewer Abandonment Plug 3 EA $800.00 $2,400.00 2 $1,600.00 26 Exploratory Excavation of Existing U 10 EA $1,000.00 $10,000.00 9 $9,000.00 27 Concrete Encase Sewer Pipe 5 CY $150.00 $750.00 1 $150.00 28 Service Reinstatement,Pipe Enlargem 80 EA $750.00 $60,000.00 91 $68,250.00 29 Service Reconnection,CIPP 2 EA $300.00 $600.00 1 $300.00 30 4"Sewer Service,2-Way Cleanout 345 EA $600.00 $207,000.00 345 $207,000.00 31 4"Sewer Service 50 EA $26.00 $1,300.00 97 $2,522.00 Friday,April 23,2021 Pa.-e 2 of 7 City Project Numbers 01503 DOE Number 6592 Contract Name Sanitary Sewer Rehabilitation Contract:XXXOV(84) Estimate Number 12 Contract Limits in the Carter Riverside Neighborhood Payment Number 12 Project Type Sewer For Period Ending 4/21/2021 Project Funding 32 4"DIP Sewer Service 90 EA $40.00 $3,600.00 156 $6,240.00 33 4"Sewer Service,Private Relocation 590 LF $60.00 $35,400.00 590 $35,400.00 34 8"C900 DR 14 PVC Water Pipe 40 LF $50.00 $2,000.00 35 Connection to Existing 8"Water Main 2 EA $1,500.00 $3,000.00 36 8"Gate Valve I EA $1,500.00 $1,500.00 37 Construction Staking(Sewer) 1 LS $15,000.00 $15,000.00 1 $15,000.00 38 Construction Survey(Sewer) I LS $5,000.00 $5,000.00 39 Construction Allowance(Sewer) 0 LS $100,000.00 $0.00 40 SWPPP >1 acre 1 LS $15,000.00 $15,000.00 1 $15,000.00 41 Topsoil 30 CY $25.00 $750.00 100 $2,500.00 42 Block Sod Placement 695 SY $10.00 $6,950.00 1150 $11,500.00 43 Seeding,Hydromulch 400 SY $5.00 $2,000.00 1300 $6,500.00 44 Traffic Control 1 LS $50,000.00 $50,000.00 1 $50,000.00 45 Temporary Asphalt Curb and Gutter 445 LF $20.00 $8,900.00 445 $8,900.00 46 Temporary Asphalt Driveway and Sidew 150 SF $3.00 $450.00 150 $450.00 47 Temporary Asphalt Paving Repair 11922 LF $16.00 $190,752.00 11922 $190,752.00 48 Remove Cone Curb and Gutter 3950 LF $3.00 $11,850.00 4950 $14,850.00 49 7"Cone Cub and Gutter(10-2-17) 5170 LF $25.00 $129,250.00 5170 $129,250.00 50 Remove Concrete Drive 5785 SF $2.00 $11,570.00 5295 $10,590.00 51 6"Concrete Driveway 6235 SF $7.00 $43,645.00 5995 $41,965.00 52 Remove Sidewalk 3080 SF $2.00 $6,160.00 3164 $6,328.00 53 4"Cone Sidewalk 3280 SF $6.00 $19,680.00 3164 $18,984.00 54 Remove Cone Valley Gutter 75 SY $5.00 $375.00 325 $1,625.00 55 6"Cone Valley Gutter 150 SY $80.00 $12,000.00 150 $12,000.00 56 Remove ADA Ramp 0 EA $200.00 $0.00 57 ADA Ramp 0 EA $1,200.00 $0.00 58 11"Pavement Pulverization(10-2-17) 6814.96 SY $5.00 $34,074.80 6814.96 $34,074.80 59 11"Cone Pvmt Repair(Arterial/Indus 6905 SY $72.00 $497,160.00 3261.5 $234,828.00 60 9"Cone Pvmt Repair(Arterial/Indust 190 SY $72.00 $13,680.00 61 Roadbond ENl Soil Stabilizer 0 GA $125.00 $0.00 62 Cement Modification(13 LBS/SY) 0 TN $150.00 $0.00 63 3"Asphalt Pvmt Type D(10-2-17) 0 SY $19.50 $0.00 64 Water Valve Adjustment(w/Steel Rise 0 EA $150.00 $0.00 65 Water Valve Adjustment(w/Concrete C 0 EA $250.00 $0.00 Friday,April 23,2021 Page 3 of 7 City Project Numbers 01503 DOE Number 6592 Contract Name Sanitary Sewer Rehabilitation Contract:XXXOV(84) Estimate Number 12 Contract Limits in the Carter Riverside Neighborhood Payment Number 12 Project Type Sewer For Period Ending 4/21/2021 Project Funding 66 Manhole Adjustment(w/Concrete Colla 0 EA $500.00 $0.00 67 Manhole Adjustment(w/Steel Riser) 0 EA $500.00 $0.00 68 Curb Address Painting 0 EA $50.00 $0.00 69 24"Striping(Stopbars,crosswalks) 30 LF $25.00 $750.00 30 $750.00 70 Remove 10'Curb Inlet 0 EA $1,000.00 $0.00 71 10'Curb Inlet 0 EA $3,500.00 $0.00 72 6"Conc Curb and Gutter 450 LF $25.00 $11,250.00 450 $11,250.00 73 5'Wide Asphalt Pvmt Repair,Residen 1105 LF $48.00 $53,040.00 1024 $49,152.00 74 Asphalt Pvmt Repair Beyond Defined W 370 SY $16.00 $5,920.00 250 $4,000.00 75 7'Wide Asphalt Pvmt Repair,Arteria 100 LF $58.00 $5,800.00 175 $10,150.00 76 Asphalt Pvmt Repair Beyond Defined W 0 SY $16.00 $0.00 77 9'Wide Asphalt over Concrete Pvmt R 215 LF $125.00 $26,875.00 140 $17,500.00 78 Asphalt Over Concrete Pvmt Repair Be 120 SY $20.00 $2,400.00 120 $2,400.00 79 Construction Staking(Paving) 0 LS $5,000.00 $0.00 80 Construction Survey(Paving) 0 LS $1,000.00 $0.00 81 Construction Allowance(Paving) 0 LS $27,788.70 $0.00 Sub-Total of Previous Unit $3,221,587.80 $2,942,782.80 Alternate B Sewer Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total --------------- - ----------------------- 1 Install Reinforced 4-ft Dia.Polymer 1 LS $6,000.00 $6,000.00 2 Install Reinforced 4-ft Dia.Polymer 1 LS $8,500.00 $8,500.00 -------------------------------------- Sub-Total of Previous Unit $14,500.00 Paving Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total --------------------------------- ------ 50 7"Conc Cub and Gutter 2585 LF $25.00 $64,625.00 51 11"Pavement Pulverization 17768.04 SY $5.00 $88,840.20 13924.54 $69,622.70 52 3"Asphalt Pvmt Type D 22694 SY $19.50 $442,533.00 22629 $441,265.50 61 Asphalt Pvmt Repair Beyond Defined Width 55 SY $16.00 $880.00 62 Remove ADA Ramp 2 EA $200.00 $400.00 63 ADA Ramp 2 EA $1,200.00 $2,400.00 Friday,April 23,2021 Page 4 of 7 City Project Numbers 01503 DOE Number 6592 Contract Name Sanitary Sewer Rehabilitation Contract:XXXOV(84) Estimate Number 12 Contract Limits in the Carter Riverside Neighborhood Payment Number 12 Project Type Paving For Period Ending 4/21/2021 Project Funding 64 Roadbond ENI Soil Stabilizer 130 GL $125.00 $16,250.00 40 $5,000.00 65 Cement Modificatoin 228 TN $150.00 $34,200.00 221 $33,150.00 66 Water Valve Adjustment(w/steel riser) 3 EA $150.00 $450.00 67 Water Valve Adjustment(w/Concrete collar) 8 EA $250.00 $2,000.00 10 $2,500.00 68 Manhole Adjustment(w/concrete Collar) 1 1 EA $500.00 $5,500.00 4 $2,000.00 69 Manhole Adjustment(w/steel riser) 3 EA $500.00 $1,500.00 70 Curb Address Painting 40 EA $50.00 $2,000.00 71 6"Conc Curb and Gutter 225 LF $25.00 $5,625.00 225 $5,625.00 72 Remove 10'Curb inlet 1 EA $1,000.00 $1,000.00 73 10'Curb Inlet I EA $3,500.00 $3,500.00 74 Construction Staking(Paving) 1 LS $5,000.00 $5,000.00 1 $5,000.00 75 Construction Survey(Paving) 1 LS $1,000.00 $1,000.00 76 Construction Allowance(Paving) 0 LS $72,211.30 $0.00 ----------- --- - - - - -- ------------------ Sub-Total of Previous Unit $677,703.20 $564,163.20 --------- - -- - --- --- ---- --- ------------ Friday,April 23,2021 Page 5 of 7 City Project Numbers 01503 DOE Number 6592 Contract Name Sanitary Sewer Rehabilitation Contract:XXXOV(84) Estimate Number 12 Contract Limits in the Carter Riverside Neighborhood Payment Number 12 Project Type Paving For Period Ending 4/21/2021 Project Funding Contract Information Summary Original Contract Amount $3,788,113.50 Chanee Orders Change Order Number 1 $344,899.30 Change Order Number P $113,509.20 Total Contract Price $3,913,791.00 Date Total Cost of Work Completed $3,506,946.00 Cont for Less 0 %Retained $0.00 / Net Earned $3,506,946.00 Date Inspection Supervisor Earned This Period $175,34728 Retainage This Period $0.00 Less Liquidated Damages Proh ject Manager Days @ /Day $0.00 N 1� Date LessPavement Deficiency $0.00 Asst.DireetodrPW Less Penalty $0.00 Lt qhg��fgge" °Ph11H,d,,(A,g5,202111:40CDT) Date Less Previous Payment $3,331,598.72 Director/Contracting Department Plus Material on Hand Less 15% $0.00 Balance Due This Payment $175,34728 Friday,April 23,2021 Page 6 of 7 FORT WORTH rev 03/05/07 � 1 WATER ENGINEERING&FISCAL SERVICES FINAL.STATEMENT OF CONTRACT TIME FINAL STATEMENT NO.:12 NAME OF PROJECT: Sanitary Sewer Rehabilitation Contract 84 PROJECT NO.: 1503 CONTRACTOR: Circle C Construction CITY PROJECT 1503 PERIOD FROM:06/26/17 TO: 04/21/21 FINAL INSPECTION DATE: 1/23/2020 WORK ORDER EFFECTIVE:6/26/2017 CONTRACT TIME: 1405 0 WD • CD DAY OF DAYS REASON FOR DAYS DAY OF DAYS REASON FOR DAYS MONTH CHARGED CREDITED MONTH DURING C CHARGED CREDITED DURING 1. 16. 2. 17. 3. is. 4. 19. 5. 20. 6. 21. 7. 22. S. 23. 9. 24. 10. 25. 11. 26. 12. 27. 13. 28. 14. 29. 15. 30. 31. SAT,SUN, RAIN,TOO WET, UTILITIES DAYS TOTAL &HOLIDAYS &TOO COLD RELOCATIONS OTHERS" CHARGED DAYS THIS PERIOD PREVIOUS PERIOD TOTALS TO DATE 1395 1395 *REMARKS; CONTRACTOR,j DATE INSPECTOR DATE Capital Projects Delivery;Water Department The City of Fort Worth•1000 Throckmorton Street•Fort Worth, IX 76012-6311 (817)392-4477•Fax:(817)392-8460 FORTWORTH REV:02/22/07 Capital Projects Delivery,Water Department CONTRACTOR'S EVALUATION OF CITY I)PROJECT INFORMATION Date: 23-A r-21 Name of Contractor Project Name Circle C Construction Sanitary Sewer Rehabilitation contract 84 Mater Engineering Inspector Project Manager Judy Die Robert Sauceda H1 DOE Number Project Difficulty Type of Contract N/A Q simpee G Routine Q Compiex ❑Water QQ Waste Water ❑Storm Drainage Pavement Initial Contract Amount Final Contract Amount $3,534,032.50 $3,992,441.00 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 y 1 Accuracy of Plans to Existing Conditions 2 Knowledge of Inspector 1 12 Clarity&Sufficiency of Details 3 Accuracy of Measured Quantities 13 Applicability of Specifications 4 Display Of Professionalism 1 14 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 2 Availability of Project Manager 1 Change Order Processing Time .� 3 Communication 2 Timliness of Contractor Payments 4 Resolution of Utility Conflicts 3 Bid Opening to Pre-Con Meeting Timeframe III)COMMENTS&SIGNATURES COMMENTS Signature Contractor Signature Inspector Signature Inspector's Supervisor INSPECTOR'S COMMENTS Capital Projects Delivery,Water Department The City of Fort Worth-1000 Throckmorton Street-Fort Worth,TX 76012-6311 (817)392-4477-Fax:(817)392-8460 SORTWORTH REV:02/20/07 Capital Projects Delivery,Water Department PERFORMANCE EVALUATION OF CONTRACTOR 1) CONTRACTOR&PROJECT DATA Nanre ofContraclor Project Name Circle C Construction ISanitarySewer Rehabilitation Contract 84 tiPater Engineeringlnspector DOE Number Judy Die NIA i ter Engineeringlnspector Project Manager rFlnal Water 0 Waste Water ❑Storm Drainage Pavement Robert Sauceda In Contract Amount Project D�cerl07 534,032.50 p Simple eQ Routine Q Complex Contract Amount Dale 992,441.00 4/21/2021 1111 PERFORMANCE EVALUATION 0-Inadequate 1-Deficient 2-Standard 3-Good 4-Excellent ELEMENT WEIGHT(X) APPLICABLE(Y/N) IRATING(0-4) MAX SCORE ISCOiE 1 Submission of Documents 2 Y 4 8 8 2 Public Notifications 5 Y 4 20 20 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 1 4 60 60 7 Job Site Safety 15 Y 4 60 60 18 Traffic Control Maintenance 15 Y 3 60 45 9 Daily Clean Up 5 Y 4 20 1 20 10 Citizen's Complaint Resolution 5 Y 4 20 20 11.., Properrt'Restoration 5 Y 4 20 20 12 After Hours Response 5 Y 3 20 15 13 Project Completion 5 Y 4 20 20 TOTAL ELEMENT SCORE(A) 428 BONUS POINTS(25 Maximum)(B) I11)CONTRACTOR'S RATING TOTAL SCORE(TS) 428 Maximum Score(MS)=448 or sum of applicable element score maximums which= 448 Rating(ITS/MSj K 100%) 428 / 448 = 96% Performance Category Excellent <20%=lnadegtrate 20%to<40%=Deficient d 0%to<60%=Standard 60%to<80%=Good >_80%=Excellent Inspector's Comments(INCLUDING EXTLANATION OF BONUS POINTS AIVARDED) Signature Inspector f."— d y/1 y /9/A. Signature Contractor Signature Inspector's Supervisor CONTRACTOR'S COMMENTS Capital Projects Deliverti-,Water Department The City of Fort Worth•1000 Throckmorton Street•Fort North,TX 76012-6311 (817)392-4477•Fax:(817)392-8460 FORTWORTH WATER ENGINEERING & FISCAL SERVICES PIPE REPORT FOR: PROJECT NAME: Sanitary Sewer Rehabilitation contract:XXXOV(84) PROJECT NUMBER: 1503 DOE NUMBER: N/A WATER PIPE LAID SIZE TYPE OF PIPE LF FIRE HYDRANTS: VALVES(16" OR LARGER) PIPE ABANDONED SIZE TYPE OF PIPE LF DENSITIES: NEW SERVICES: SEWER PIPE LAID SIZE TYPE OF PIPE LF SEWER 18" HDPE 855 SEWER 1611 HDPE 4675 SEWER 16" HDPE 500 SEWER loft PVC 690 SEWER loft DIP 45 SEWER 8" HDPE 3965 SEWER 8" PVC 6273 PIPE ABANDONED SIZE TYPE OF PIPE LF SEWER 12" CCP 855 SEWER 10" CCP 4675 SEWER 10" VC 500 SEWER 6", 8" CCP 10238 DENSITIES: 36 NEW SERVICES: WATER ENGINEERING&FISCAL SERVICES The City of Fort Worth•1000 Throckmorton Street•Fort Worth,TX 76012-6311 (817) 392-4477•Fax: (817) 392-8460 CSC No.48254-CO3 F®IR-r Wa nT -II E City of Fort Worth 1r— Change Order Request Project Name:1 Sanitary Sewer Rehabilitation Contract LXXXIV(84) City Sec No.: 1 48254 Project No.(s): 56oD2-070043o•CDt78D DOE No. N/A City Proj,No.: 0—5 03 Project Description Sanitary sewer main replacements on Honeysuckle Avenue,Springdale Road, Brittain Street,and Elinor Street Contractor: William J.Schultz,Inc.dba Circle C Construction Co. I Change Order# 3 Date 3/8/2021 City Project Mgr.1 John Kasavich City Inspector: I David Johnson Phone Number: 817-392-8480 Phone Number: 817-392-8455 Dept. Sewer Alternate B paving Totals I i Contract Time Sewer (Calenderdays) Original ContractAmount 2,955,369.30 1 '500.00 56 ,163.20 3,53 ,032.50 400 Extras to Date $344,899.30 $113,509.20 $458,408.50 1855 Credits to Date Pending Change Orders(in M&C Process) Contract Cost to Date $3,300,268.60 $14,500.00 1 $677,672.40 $3.992.441.00 11.255 Amount of Proposed Change Order $0.00 $0.00 10.00 0.00 150 Revised Contract Amount 3,300,268.60 $14,WUMU $677,672.40 $3,992,441.00 11,405 Original Funds Available for Change Orders $355,000.00 $44,600.00 $399.600.00 Remaining Funds Available for this CO Additional Funding(if necessary) I I CHANGE ORDERS to DATE(INCLUDING THIS ONE)AS%OF ORIGINAL CONTRACT 12.97% MAXALLOWABLE CONTRACTAMOUNT(ORIGINAL CONTRACT COST+25%) $4,417,540.63 JUSTIFICATION(REASONS)FOR CHANGE ORDER Change Order No.3 will provide an additional 150 calendar days on the project for the time to satisfactorily resolve all pavement issues after the project was completed. 1 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. Contractor's Company Name Contractor Name Contractor Signature Date I. William l Schultz,Inc.dba circle c construction Co. Teri Skelly f p�n�� .1� ���^�JI j&2,1-" Insptor Date Project Manager Date Director(Water Dept) Date I Constr Lion Supervisor(Water Dept) Date Chrrsl-nphCrNgrAnr __ _. s.s- Mar15,2021 I /9-/X/ - u ssistant Ci Rtfomey ,. Date I Assistant City Manager Date Mar 16,2021 Mar 16,2021 Council Action If Required M&C Number NIA M&C Date Approved EAls�—� FORT NORTH City of Fort Worth Change Order Additions Project Name Sanitary Sewer Rehabilitation Contract LXXXIV(84) City Sec No.: 48254 Project No.(s): 56002-0700430-CO1780 DOE No. N/A City Proj.No.: 01503 Project Description Sanitary sewer main replacements on Honeysuckle Avenue,Springdale Road,Brittain Street,and Elinor Street Contractor William J.Schultz,Inc.dba Circle C Construction Co. Change Order:=3 Date: 3/8/2021 City Project Mgr. John Kasavich I City Inspector FDavidJohnson ADDITIONS —TrEM-- DESCRIPTION DEPT Q Unit Unit Cost Total Sewer Alternate B Sewer Paving Page i of! Additions Sub Total Foo1Z-' Vv®,R-F 1-1 City of Fort Worth Change Order Deletions Project Name Sanitary Sewer Rehabilitation Contract LXXXIV(84) City Sec No.: 1 48254 Project No.(s): 56002-0700430-CO1780 DOE No. N/A City Proj.No.: 0 5503 Project Description Sanitary sewer main replacements on Honeysuckle Avenue,Springdale Road,Brittain Street,and Elinor Street Contractor William J.Schultz,Inc.dba Circle C Construction Co. Change Order: F73 Date 3/8/2021 City Project Mgr. John Kasavich City Inspector: FDavid Johnson DELETIONS ITEM DESCRIPTION DEPT Qty Unit Unit Cost Total Sewer Alternate B Sewer Paving Page 1 of 1 Deletions Sub Total MIVVBE Breakdown for this Change Order MVIIBE Sub Type`of Service ;4mount for this CO Total $0 OO r LL Previous Change Orders Total $0 00 Page 1 of 1 Contract:Compliance Manager By signing I ackaowledge that I am the person responsible for the monitoring and administration of this contract,including ensuring all performance and reporting requirements. Signature V F�f'fiy� �- ���✓��G- Name of Bmployee (F Title ATTEST: G Mary Kayser City Secretary i I z k h 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 TERESA S SKELLY, PRESIDENT of CIRCLE C CONSTRUCTION, known to me to be a credible person, who being by me duly sworn, upon his oath deposed and said; That all person, 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 damage; On Contract described as; Sanitary Sewer Rehabilitation Contract LXXXIV(84) City Project Number 01503 BY Subscribed and sworn before me on this Day of� 1Q� , 2019. „u Not Public in Tarrant County, X PPaY Pray,MICHELE S LANKFOR �y Notary Public * `a< STATE OF TEXAS Nottery ID#1175946-6 Comm.Exp.October 7,2023 CONSENT OF SURETY OWNER TO FINAL PAYMENT ARCHITECT ❑ AIA Document G707 CONTRACTOR ❑ SURETY ❑ OTHER ❑ Bond No.TXC608012 TO OWNER: ARCHITECT'S PROJECT NO.: City of Fort Worth City Project No. 01503 1000 Throckmorton Street Fort Worth,TX CONTRACT FOR: Utilities CONTRACT DATED: August 16,2016 PROJECT: (name,address) Sanitary Sewer Rehabilitation Contract L30MV(84) in the City of Fort Worth,Texas In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above,the (Insert name and address of Surety) Merchants Bonding Company(Mutual) 6700 Westown Parkway West Des Moines,IA 50266 ,SURETY on bond of (Insert name and address of Contractor) William J.Schultz,Inc.,dba Circle C Construction Company P.O.Box 40328 Fort Worth,TX 76140 ,CONTRACTOR, hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall not relieve the Surety of any of its obligations to (Insert name and address of Owner) City of Fort Worth 1000 Throckmorton Street Fort Worth,TX 76102 ,OWNER, as set forth in the said Surety's bond. IN WITNESS WHEREOF,the Surety has hereunto set its hand this date: October 30,2019 (Insert in writing the month followed by the numeric date and year.) Merchants Bonding Company (Mutual) (Surely L� (Signature of as ,.need representative) latest• fitness as to Surety: Sheryl A.IGutts,Attorney-in-Fact (Seal (Printed name and title) John A.Miller 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•AIAO One Page ©1970•THE AMERICAN INSTITUTE OF ARCHITECTS,1735 New York Ave.,NW,Washington,D.C.20006 MERCHANT BONDING COMPANY-. POWER OF ATTORNEY Know All Persons By These Presents,that MERCHANTS BONDING COMPANY(MUTUAL)and MERCHANTS NATIONAL BONDING,INC., both being corporations of the State of Iowa(herein collectively called the"Companies")do hereby make,constitute and appoint,individually, John A Miller;John R Stockton;Sheryl A Klutts their true and lawful Attomey(s)-in-Fact, to sign its name as surety(ies) and to execute, seal and acknowledge any and all bonds, undertakings, contracts and other written instruments in the nature thereof, on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law. This Power-of-Attomey is granted and is signed and sealed by facsimile under and by authority of the following By-Laws adopted by the Board of Directors of Merchants Bonding Company (Mutual) on April 23, 2011 and amended August 14, 2015 and adopted by the Board of Directors of Merchants National Bonding,Inc.,on October 16,2015. "The President, Secretary,Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority to appoint Attomeys-in-Fact, and to authorize them to execute on behalf of the Company, and attach the seal of the Company thereto, bonds and undertakings,recognizances,contracts of indemnity and other writings obligatory in the nature thereof." 'The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney or Certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the Company,and such signature and seal when so used shall have the same force and effect as though manually fixed." In connection with obligations in favor of the Florida Department of Transportation only,it is agreed that the power and aut hority hereby given to the Attorney-in-Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of its obligations under its bond. In connection with obligations in favor of the Kentucky Department of Highways only,it is agreed that the power and authority hereby given to the Attomey-in-Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner- Department of Highways of the Commonwealth of Kentucky at least thirty(30)days prior to the modification or revocation. In Witness Whereof,the Companies have caused this instrument to be signed and sealed this 6th day of April 2017 •,.••Pt10N,4,e••,� •;�.�Q• , RpQR• �O`L ;•OHO sPQAq'. MERCHANTS BONDING COMPANY(MUTUAL) 9��.2. 0 A9,;.y�; MERCHANTS NATIONAL BONDING,INC. 2003 1933 c: By .,.�'•••... . ;'�.. .6,�' a .,� ''�J•. !y"�'•'`'�,: President STATE OFIOWA ••••"•• "''``' ••"••'•`• COUNTY OF DALLAS ss. On this this 6th day of April 2017 before me appeared Larry Taylor, to me personally known,who being by me duly swom did say that he is President of MERCHANTS BONDING COMPANY(MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the seals affixed to the foregoing instrument are the Corporate Seals of the Companies;and that the said instrument was signed and sealed in behalf of the Companies by authority of their respective Boards of Directors. F�-6w�" AUCIA K.GRAM Commission Number 767430 My Commission Expires April 1,2020 Notary Public (Expiration of notary's commission does not invalidate this instrument) I,William Warner,Jr.,Secretary of MERCHANTS BONDING COMPANY(MUTUAL)and MERCHANTS NATIONAL BONDING,INC.,do hereby certify that the above and foregoing is a true and correct copy of the POWER-OF-ATTORNEY executed by said Companies,which is still in full force and effect and has not been amended or revoked. In Witness Whereof,I have hereunto set my hand and affixed the seal of the Companies on this 30th day of October , 2019 . +:y :XvLPOQ•9•�p:, 00••OF1PUgq'gy: h/, i=s' � 'G �':y: .y. G .�•..c� mac/ �.s��. j 2003 1933 :c• Secretary POA0018 (3/17) •�'`'�••'•'•••'` '••••••• FORT WORTH i April 23,2021 William J.'Schultz,Inc. dba Circle C Construction Company P.O.Box 40328 Fort Worth,TX 76140 Re:Acceptance Letter Project Name: Sanitary Sewer Rehabilitation Contract:XXXOV (84) Project Type: Sewer Project Ns: 01503 D.O.E. Ns: N/A Contract Ns: 48254 Dated: 4/21/2021 Gentleman: On January 23,2020 a final inspection was made on the subject project. There were no punch list items identified at the time. The final.inspection indicates that the work meets the City of Fort Worth specifications and is therefore accepted.by the City. The warranty period will start on January 23,2020,which is the date of final inspection and will extend for (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) 392-6054 Yours Truly, Tony Sholola,P.E.,Assistant Director Water Department MP / cc: Chris Harder,P.E.,Director,Water Department Laura Wilson,P.E.,Deputy Director,Water Department Captain Michael Strains,Fire Department Cesar Zavala,Field Operations Superintendent,Water Department Bill Lundvall,Field Operations Superintendent,Waste Water Department John Kasavich,P. E.,Project Manager Chris Brooks,P.E.RJN, Consultant Teri Skelly, Circle C Construction Company, Contractor David Johnson,Inspection Supervisor,Water Engineering and Fiscal Services Judy Die,Inspector,Water Engineering and Fiscal Services File WATER DEPARTMENT ENGINEERING AND FISCAL SERVICES THE CITY OF FORT WORTH * 1000 THROCKMORTON STREET * FORT WORTH, TEXAS 76102 817-392-8240 * FAx 817-392-8195 Q. Printed on recycled paper DB-0154 Revised 3/11/2013 MONTHLY DAVIS BACON ACT CERTIFICATE of COMPLIANCE Submittal by Owner (Sub-Recipient) TWDB Project No. 7 2 2 729- Loan/Grant No. L a 10 ©D 3 This executed certificate must be submitted with each Outlay report for labor included within construction contracts. This Certificate applies only for LOANS CLOSED AFTER 10/30/2009. I, un&.1 e r of (Name)A� itle) �Or�' e e-4--k �tvcV�r"N ere y certify that reviews of a representative (Name of entity) sample of the weekly payroll data, and contractor weekly payroll certifications such as OMB No. 1215-0149, have been performed to verify that contractors and subcontractors are paying the appropriate wage rate for compliance with the DAVIS BACON ACT, 40 U.S.C. §§3141 et seq. as amended and in conformance with the U.S. Department of Labor regulations at 29 CFR Part 5, (Labor Standards Provisions Applicable to Contracts Covering Federally Financed and Assisted Construction) and 29 CFR Part 3 (Contractors and Subcontractors on Public Work Financed in Whole or in Part by Loans or Grants from the United States). I understand that a false statement herein may subject me to penalties under federal and state laws relating to filing false statements and other relevant statutes. Sig ture Date TWDB-0550 Updated2/10/2015 Page21 Ca 'IT NUMBER LABOR STANDARDS li nRVIEW TWDB Project ID: 72275 ?L'4YEE,NFOEMMG NAAAEOG � 'LA�rLA. E s.AS ME Co � C—ircae_ G h �- p c t NAME OF EAL:L.,7yER -ERE67, p;q� ► 4 ✓Ca «rY 'd -1 127vL'. T6_ 71P`OD SUPEAtRSOR S!r1Aa1E r 'Ij"!'Yl I tAST NAME FIRST NAME J M1 WORK C ASSC-I.CATION 7N,4r=RATE SV I'1 ACTrON CH CK BELOW Do you work-ouer 8 hours per day? YES NO V Do You work over 40 hours per week? Aire Vou pa:d at least time and a half fur overt15ne hours? Are You receiving any cash Payments far fringe benefits required by the Posted+vage determination decision? l4HA a iIEDUa.TiaZ,YS OTHER'1t.rAN Tp„t¢g Ata2 SOCIAL SECi7R1T'i ARE A7'p.�.E FROM YOUR PAY? Ir. LD r-Q..Ln M-PWAli ;10 10 0J' O ON Y ST - A THIS INTERI+MW? IDOL;YOU USE DATE OF LAST WORK DAY BEFORE 1<1R;,.RVIEW!YY,NdrC + 1 � - DATE YOU E'{,,at1 0 .,, IS? YEE'•S 3 3NE AWVE eS Cop.;ECr TO THE EE;T OF My Kr40WLEG;E aJ,A'_ DATE! DD1 SIGNATURE :YreG OR PRINT ED NAME / / IN.ERVIEW�r'F.k DATE ,+5'Y64.d.W) WORK pn�LO -7w. n+t:E i 1Ni 1 ,ycD ItJTEtIV#ET1StEl:"Cdikll#V1F?lTS Acmau(JP urphraSom,c nocdad,use mmmmts Sacdim) YES NO rS EMPLOYEE PROPERLY CLASSIFIED AND PAID? it#��LHJSGE AATES 0'POSTE5M ZIMP A SO? FOR USE By PAYROLL CHECKER rS�6YFORh1AT3,Y rlv AGT�EiV1E1T W!;#3 PAj`ROLL DJ1;A? n ND M1R'�-NTS CNEC.KER' LAST NAME Al E MI JOB TM-EDATE 1YYdtt�7D) AUTNOR=b FGR LECALFI trC 3%. / /(� Prwrcouc adi8aa wt o STA11rDARD'FORM 1445 REY_t Rv=-nbad by GSA-FAR i48 CFRr 53.2Z'fiil DB-0156 10/1I3/2010 Page 21 EABM STANDARDS INTERVIEW OS71M'TRALT HIiMBER TWDB Project ID: 72275 LAST 37AY P+ePtUYEEwFOs:MAT1oN NlkME 4FFi?iME O CTOR T NAM irks. G gyro e- ) E MI NAME OF Edf�LOyER STREET AD ^S SUPESNISUWS MA.V.E STATE 12 CODE U.ST NAME aRST NAME �Or\ M V.ORK C 11 , . ArION WAGERATE I �� t V ACTFON CHECK BEL{3W Do You work over$hours YES No per day? Do you work over 4.1' h'QOrS per waek? Are yaw pain at least time and a haEf for overtime hoara? \� Are you receiving any cash Payments gar fringe benel required by the posted wage determinetior:daci3ion?AHAT oEDUCTit¢Y5 OTHER T3dAN TA�SES At:D SOCIAL SECa1RkTY AAE MADE FA06!YOUR?AY2 V =nSu r Qa.-t How u0 3i1 R R LA, 43:C DA E THIS RW;FRy7EWt TOOLS YOU USE DATE OP lA.*"T v+'�RKI]AY 8EW RE •ERVIEW JYY6trLfDD1 Q DA E YOIa '.O: � 'S• � EGT. DD,I EMPLO SIGMTU THE ABOVE SS COQRWr TO T4E Ea`ST QF AdY'KN04A'LEL'isE DAT INTERVIE -1A S16NATURE i+'1%ED OrZ P RlN.EDNAM� DATE f4YLYBdDDJ <EM YEE WA5 L'vi NHENl l viEAED I6YFEETWBEriNER S CDISDME11fTS / / AC11021 Ilfn�:�r is noodad, eso narnrncr�sxbvnl YES NO rS i MPLOYEE PROPEFiY CLASSMED AND PAID? AP. V.Ytt=E FrA i ES ANFD pOSTEfi"'Jl PL4YED3 IS WEWORMJITIN Rr_A6PFEVE1TShITFi?i1YROLL]AFDRI7SEBYAAYfiOLiCk1EEiCEE� YES NO MINTS LAST NAME CHECKM Ct PI AM RE e ,� UIC- JORTITLE —NATURE f AUT AI2J= i•OOAi ODl:C170M S + ��� at:odi hon STAAIDARE?FORM 1445 e'.REY-72 95) P.--mane br GSA.-FAR ySS 4:FRI S3.222(w DB-01S6 20/18/2010 Page 21 LABOR STANDARDS INTERVIEW COkTRADT NtiM89i TWDB Project ID: 72275 04PLOYEE WP6IR MMIOPJ NJAMS ECOMMACTOR UASTfaA.'VIE a AME C Y GI e. C, •S� . NAME OF KNE'LDYER J SUPEt','IRST NA M1AE {� � 1— ,ti E_ CJ00 . Lk..`"T PJJIME 'lRS.'r ldAR45 1 r l I, l0�- � MY WORK yCLASSGJCATION {AMA RATE ACTION �a . CHEC9C$ELIDLY Do you work over 8 hours per day.? YES NO Do you work over 40}lours per week? Are you paid at least time and a;half for overtime hours? Are You receiviiag ar,y cash SE pa ents ym fort fringe bersafrts required by the pasted wage determination dec�1 n2 1VHAT JDlFLTrCyS OTlJER 7HAN TAY ArL3 SOCIAL SECUP�ryr AAE A k:FROM YOUR?AY?HOW V i ivDItRS 6U 0 041. R Ld.3 ayax THIS IN iERwEM uu"Ya[9 U DAT d!r LAST W&I:IK DAY BEFDRr RVIEy!JYYM'AfDJlI DATE BE 0 _ PIA S 3t ;ATtI THE ASOYE LS COsYRECT TO THE JEST OF[uY KWC/IkLEOG' DA E! df* INs ERYIE'i4=R SIGNATIMS ;FAO OR pR1NTE0 NAME / / DATE+'YY.6yrdOp) 4F.d ch1PL0 E VIAS D0 NE`J Al D Il11TEF3V6EliYEH S UUMMENTS A 02t fJf wp a"yM-is nrodad,a ro+ .1t ecew) YES NO :S EMPLDYEE PROPEMY CLASSk'.1M AND PAI71 ARE WAGE RATES AM pWrEM DIAYE0? E 4NFOR61ATp'v.Y IN AGlti]::R 6JTVwIFH pJSYRO)1.7A 0R aY:FAYFTQLL {ECKER YES No U04TS EAST ME CHEC2CER FT� 7dl� JOBTITLe �0 S Inspector DATE r ,yry�tppJ AA47MORI FORLDCALRO410.�AiCTlON Ptaviorr ediAioaa race ar�(o STARIDARD Fi7RM 1445!r46V_t 2-e6) A;emriboc by GSA-FAR,=CFR}52 222(?I DB-0156 10/18/2010 Page 21 LABOR STANDARDS INTERVIEW +1:DJ:TRAia'1'Nt;M9E9i TWDB Project ID: 72275 LA E kkkSSS,,, MrAOYMINFWMATIGN NAM Or FRfM ONTRA OR /� T NAME (^,I��hh . C 1 r w� STREET ADDR69S' NAME 4F G Gore _ M SUPERVISOR-S7; ve SFd IPCODE NAME 1ST NAME� Y I, Mi V N C�.AWt--(CATION VIAGE RdTE IS .35' ACTION CHECK BELOW Do you work over 8 hours YES NO pea day? Da You work over•4O hours Per Week? Are you paid et least time and a half for overtime hours? Ave you receiving.any cash payments for fringe benefits required by the Posted wage demrmhMation deciaion7 WHAT aSDIACrTeLyltS O4S3Bi THAN TA7t9;3 AtC•�sOCIY6,L,^-Ci1"rgTY dRE h{AIDE FROA!vQiFR PrLv? THIS IM".ERSpE'Jit'T TO©LS YOU USE DATE Or tJSST WJRK DAY PARC r.,L T�.'(YYMLIDDI l"dMDD) THE A9GVE;S CORRECT TO THE FX OF MY KF3OLYLEG;7 DATE Irii1N1.'DD1 INTER m-ER SIGNATURE Flu": :I OR PRIWED NAME DATE�YYAWDD1 INTERVIEWER'S 0DII91J1�JTS / ..AtisIO.VIlIV`axv.(va�zcw=rjo eod%-mwcammoatssa_tionyl YES NO fS Er PLOYEE PROPreLV CLA=FIED AND PAI]? ARE WAGE RAT ES A=POSTE;ti'DMF AYFD? SdBOAfE6YFORhiATh:,'V "AG EWOTrW....?AYROIJ!OA OR[D5�67F.PAYfi41-.1_�C}IEEDILER YES �ND [+uMM[LNFS t-AAST NAME CHEC:fEti s=S '=1 TN b+ll J06TITtqk s E'• A RMED FOR LOCAL RIPMOUCT30N h°=cdi5ar STANDARD FORM 1 5 r?EV_12-M P,+ocnrk:ou by GSA-FAS:36 C-fll 53-Z22CvJ DE-0156 10/18/2010 Page 21 LABOR STANDARDS 1WERVIEVhI ODkTRACT Nl:7ABER TWDE Project ID: 72275 RR—2fLOVEEINFGA Me LAST"rtA.1AE NAM NAME— PRt1dE COLdFRACrOR ' 7 C'r c-� � C SE'REET ADD�t6SS �• STATE P CODE SUPE4VISOR'S kmE LSST NAME . T NAME MI W RK S,L TION WAGE RATE ACT[D,Y CHECK BELOW Uo you work over 8 Hours per days YES me Do you work over 40 hours per week? Are you peed at least time and a half fo:overtime hours? Are you receMng any cash psyrrents for fringe benefits required b the Y posted wage determinaion decisior,7 \ 1VHAT aEDU;.TaL\14S OTHER T61AN TAXES At:'D 50ClAL 1:4[t i YOUR FAY? w An I,_L�r�nrQr , LA Dar i RS INT ERV±EW? ;170ES Y lUU USE DATE OF L4 L VmPK'DAY HEPOR^LYTERVIEV!!yyNAfDDD) DATE YOLD 1 OW , 1 E PLA THE A80VE IS O06LREOF TO WE SEST OF My KNOVJIEC�;=_Y '3 SICdtt-R,E DA E ryry SIGNATIh;E TYD Or2 PRIN eD Na4,Me IN�RVIEW�R DATE/i1�A!54A71 Wove o Eva ,alw wl,Ev i ONEILSiTERVlEVNEB'S / C[IL4111t11£ 1S / AC;10?liffnxvb=6"i--dad nsocammm,=xaaev) YE3 NO rs EMPLOYEE PROPErd-V MASSIFtED AND FAR]? ARE WAGE RATES AIM PC.S M 7r pLA-'ED? FOR USE BY'PAYRQLL CHECKER IS E WCORNIATxO.1L Re A�'P= E;tf VJ ATA? f�H PA'Y'ROLt 9 YES ONO M rE!Y'FS LAST NAME MECKER r"7 M 5dI ,lO6TITLE ? 4 4 Cl SSCN t C_- ATt1RE DATE f A RI2ED F3R LOCAL � /3 v L �a : ` aeSiSon rw: STAXI)AR©FORM 7445 L4EY_i2�6a Promo d by GSA-FAR i4S±'rRI 53.222IS7 DB-0156 10/18/2010 Page 21 LABOR STANDARDS INTERVIEW CDhTRAGT NSIMBER TWDB Project ID: 72275 LAST t63 OYMINFWMA�ON ME OFF'am CONTRAL70A , E aJ y NAME 411 c�l GCoY1F� � NAME pF MoLqr.R L'Jr_ ADDRESSS Crry SUPDtViSOR'S d21lay1E r T `rAF. P CODE :—.Tr NAME FI �r NAME T f MI lA'OAK CLx�SSt.0 TIAN� ACTfdN CHECK LLOW 00 you work over 8 fours per day? YES NO 00 You work over-1,0 sours per week? Are you paid at least time and a half for overtime hours? Are you receiving any Cayh payments for fringe benefits required by the posted wage determinaidon decision? WIRK,9EDL'.^.7EAlt$O3FI13i "'Um TAXES.AAD SOCIAL:EC11P17;�•ARE NWDE FAOh9 YOUR FAY" MANY No- 'DID y R S D RE THIS IN-ERViE14Z OOCS YOU USE DATE OrEASC WORK GA't EFO iNURVI!Y1Y�LL4;SD1}J 7A.TEY O7 . 'wo O. , S f IJd30DI,.7 .1 Y 'S SIGfiA RE TEIE'48OVE i5 COP�ECL TD THE 9.:ST OF h!Y KNDlh'LEC;,,.t DATE f SIGNATLrRE INTERVIR,vm —t!?ED OR Pf#INi ED NAME DATE fYY,%A4=DJ wo= YE= aW r�wl�E lrrr D "NTERV1iEWER'S.CUA7719£MP8 A:�IOatlfFarp,�rr�6cir,i:eoulad,rrccruramwAssaa�anl YES NO IS EMPLOYEE PROPS'--Y CLASSIRED AND PAID? AFLE'VlAGE RATES AND P asr2`,.9'D.6—RAYED? A VEWFOAMATiv:1 R�AGF vY,81TVfIrypA1'ROI1s7AMRUSEBY'E*�I1,YR0lt.Q•}fECiiER Y� NO .=hfTS LAST NAME CRECKERi 1R5. �Jr � }ill JORTITLG � E Inspector TFSDRIZED f�R 6iEPRO,7L`CT'DIv " //3 `V Pravea=odic e¢a7ila - STANDARD PDRM-1445 ragV 12.3fi) P =fil a W GSA-FAR i46 CFRr Sd-222r1;3 DB-0156 10/18/2010 Page 21 COW—, LABOR STANDARDS INTERVIEW NIJARI32 TWDB Project ID: 72275 ErMOYEEfAlFWMA�rON J:AS. E RS' NAJAE 3F � L:ONTRAOTQR DRI C4 Y� STREET ADDR= N E W 65A?LDm � rCA SUPERWSSOR'S'NAME � TE PC De Lfr NAME F1 NAME �^ rd! V. RK C,gggtECAT14N W+4^�RAFE ACTION CHECK ELOW Do you work Over 8 hours YES NO per day? Do you work over40 hCUrS per week? Are You paid at least time and a half for overtirns Fours? Are You receiving any eali payments for fringe Benefits required BY the posted wage determination decision? WHAT DEDUZ:MVS OTHER Tr1AN TAXES dajo soclAL SEDUR,7ry ARE MA®E 1—M YOUR PAY+ Zv1, Y' 0 M a YO iOR'DAY RE THIS INi6RN 9W. L - TOOL:,Y047 USA DATE OF LAST WORK GAY BEFORE CiTER I_NW fYYIt4AfDDJ DA OU O 1+ PR C YeM,1,001 E PLOYEE S G THE ABOVE IS C:OTLRECT TO THE Sa T OF my KNQ WLEDG.< DATE SIGNATURE IN ERNffiW=R PRINTENAhE DATE_Y71M4ppl w Fx MPLO L vWA :3Zn0 WI4E? r ERVIEWED ::::t[frTEf31ICELVEF3 5 CC?C.gMEhTFs / / AC?IONrPfaruflovri:,naadad,tam•romrnosactiaaJ YES NO !S EMPLOYEE PROPSUX CLASSi1ED AND PAID? ARE 1b'AGE RATES A?lp p„-STETS DtSriAYE67 S L�—,L'--1111:101 Irr AGC EYtE tT VdITH PAYROLL pA�R USE 8Y pAyBOLL CHECKER NOs LAST NAMEH" MI JOSTITLE GNA, RE aL��7� C Inspector GATE{ A HDRfZED FOR' -REPRODt;CnD&' vea�editi .tr.�,[o STANDAR©Flitim 1445 REV 42.9dr Pvscrarod by GSA-FAR{46£FRf 59.272I�C) DB-0156 10/18/2010 Page 21 CCliTRACT LABOR STAND ARDS INTERInEWit N6'M9ER TWDB Project ID: 72275 EMPLOVEE WFwaaA-?ON NA Gpr-;UM G GT{?R ALA a�,14AAAE R�tiI+lME 1, 11 C YI Nay!€ C;TY SUPETMSOa•SWAIVE- Sr EE IPCODE LAST NAM ,. T AAIE MJ VVORK,C�SSE�CATION W �IM Ip0 IAGERA IVI)1�}1 e�/ 139 ACTION CHECK BELOW Do you work over 8 hours per Jaya YES NO 00 you work over 40 hours per week? Are You paid at least time and a half for overtime hours? Are You receiving.any cash payments for fringe benefifs required by the Posted wage determination deaision7 WHAT U=_Dq.TTi.^.ygz TH.CN T,A]{=.>A4t'/SOCUIJ,SECUkT}Y'ARE MADE F AAA4 YOUR PAY? HOW AMY Hn7L S RLAST'. THIS INTERY;EW? �OFS Y{fL USS DATE OF EA,�F W�?RK DAY A 6�1T£A�IE4Y'YYMd{Lp D 'bE Ol:EEG : O I i 0 THE ABOyE!S COE.RLx:T TO 7?IE SST OF❑4Y KND�hLEC„E eMPLOYL'S SIGklY DAT � ! INTERYIEVTeft SIGNATI RE YPED 02 PFUN ED NAME DATE!Y?;1{�(y1 Oa WI PLOY WAS awH ,L ItSE ;EW-eD INTERVIEWER'S COEk91'dl£SJF$ / I AC-.II pf o Gorr is nadvd,zcv rammanrs za&j rl YES NO IS EMPLO7fM PROPEILY CLASS--RED AND PALL? Aln WAGE RA—,ES AIM PasrLx=nr�-R YEC? 5 AMYrtljFORh'IATSO,V:Ik AGF£EtdE,liT1MIeHx�AYROLI9A�R�� BY PAYRCII�CiFIECKER YES n NO MCs3Jr5 '� +=HECKEA GYA.TEIhAE a.J'P��j ��IC .losTiTL=.T «ds PM DATE//Y//�,Af;G,/ AL•-r RIZED F-0iR ii3 aEPR0�7UC7�Dil' -7S ' (� wt�atliScvs x o STANDARD FORM 1445 L rv_42-gs) 'P6W=nbvu by GSA-FAR j4a CFRI Sg_222jVj DS-0156 10/18/2010 Page 21 LABOR STANDARDS INTERVIEW COhTRAC'TNGMRER TWDB Project ID: 72275 LkAM BXPLOYMfly PMATION E OFM CONTRAMR a✓ ME iw`! Ct�e�(, �� -N . STU ADDRESS A E 9Lt2[DF' .�trER - v e SUPFAVISOR S AAAfE ATE Zip CODE LA NAIdE FI T IAME Id: V�'pAK C7+.4SSPICAMN Y � U V.AG��RA:'E l 38 5 ACTIOMCHECK iSEF_Ow DO You work over 8 hours YES NO per day? 1 DO You work over 40 hours per,week? Are You paid at least time and a half for overmna hours? Are you receiving any cash payments far fringe benefits required by the posted wage determinafon decision? WHA7L,7ED1.iL'3 i.^xY5 07k{Eq T.iAI11 TA�C£S,AT SACIp,L SECUR6Ty ARE MADE FgOM 1'dliA AAY? O M Iv6it. i Y FIX ON YOUP.LAST 314I3 INtERY;EW? Too You USE DATE OF LA-IT wGRK DAY 90,0AE&WTZRV q ,{}.rig DATE YOU t NO I ROWS O MPLO THE ASOVE IS COERECT TO T+IE�T OF My Kr7OW ED32 EES SIGfW J:,IE DA (:YY ;AL1D1 SIGNATURE IPliERS�IEWER Yc'cD OZ PRIM€D NAME DATE!YM+1S=J WOKK E:MPLAY UWJL's Gi ^yq HE:L I ERV;EWED IL51TfRVtIEVLrER'S CflPYIaUIElVl'S / / AC71070�ff caFJanaScn k nacho eao r orn rfat saeCcvrJ YES NO LS EMPL;DYEE PROPM-Y CL.A:MRSD AND PAID? AM WAGE RATES AND P.CMERS DtZpUyEDT FO USE BY'PAYROLL CHECKER BOVE IINVORMATAO4 IN AGRS6WE J:T wl i H PAYROLL DA o A? YES El NO ICO M= CHECKER 6l7., 'FIRST IUE �KAt S a /Ll w1i, JOBTLTIE DATE( ic�A`?J RIZED Fa S tO RO0ISCnd6y '9�od o STANDARD F"M 1445 LREM.t_-ss) Ftrvxnlwd by GSA-FAR i4e CFR!53_TZFW DB-0156 1O/18/2010 Page 21 LABOR STANDARDS INTFRV EW ODkTRACT Nt,'MHEME TWDB Project ID: 72275 Rd LOYEEINMRMATION CDNCRACTflR C'1�LJl A:WE W11 NAMo^vF�tJ � R^S �ME y� ADDRESS I STAEEr NAMFy4r ENp^[r3YER SUPSRIMOMS O<lW.E ATE 2'IP E 'T NAME Pi V Cy�NAME O N / �—•+ll.�� hli 1Mp K,i SSC-ICATIO WAN-.RATE �D J ly ACTION CHEC9C$ELflW ffQ Do you work over 8 hours per day? YES Do you work over 40}lours per week? Are you pa€d at least time and a half for overtime hours? Are YOU receiving any cash Peyrreents for tinge benefits,required by the posted,wage determinat€on decision? WHAT DEDUCTJa,mS OSHER TJ+APJ FAXES AtA?SOCIAL:rECURIFY PAE GtAOE FAOAI YOUR FAY2 L40W MMY kOh Y N OUR _7C a7 Y H.FGRE THISIMERVIEU1'2' I"( TOOILS YOU USE DATE OF LA^F WORK CAG RE LI - IEW NVAMrg) L QA E .d a P�O?,I - 1'%LL rD:31 EMPLOYEE-SS Tdllu THE ABOVE M CORRECT TO THE AST OF MY KNOWLGCG= DATE d raD) SIGNATURE Yr£D OR PRINTED NAME I I IP7iERYlE1ACeR DATE!4YM4.I M; WORK°a1PLA tx f13'U,x -E7C INTEdY EhLED MIIOTERVNEWER S C►ta;IUMMff:S =ACvr& d era•mrarawzls�ve6vr f YES NO -Y CLASSL1ED AND PAID? d7 PDSF ,E'3 D'r3pLA,YED? FLDR USE BY PAYR LL CHECKER iS ABDWE LVFDR—JS h-d fY AGREEMENT Wfi H PAYROLL DKZA? n ND CDM , CHECYE4 �� y AhtE 3AI JOSTISLE sl.;WLTURE DATE;r ALrrF•i RI2ED FOR 30 R aucTJD STANDARD,FDRM 74.45,tEY t2-9SJ Pam.. odr'L'a�mt A-aser+bwl br GSA-FAR i4r CFR}53.222[1r] DE-0156 10/18/2010 Page 21 LABOR STANDARDS INTEMEW OOh`TR0.CT NL;MHEii TWDB Project ID: 72275 � �-4' INFORMATION NJUAEOiFPC,itAECONTRA R •L0. c LSVE C 141E , I NAME EMPLOYER SUPERVISOR S X&VE �I (_ SLAT 2`1P CODE NAME .:'SNAME hU VL+ORK IC44SSs'ICATI ON V m RATE I 1 SO ACT[ON CHECK BELOW []a you work aver 8 hours per day? YES NO Do You work over 40 hours per week? Ara you pe:d at least time and a half far overtime hours? Y receiving any cash payments for fringe benefits required by the posted wage determination decision? AreWHAT OEDLM7rirCANM OTHER T THAN TA'CE5 ATrJ SOiCL4L gE:CUkfCr ARE MATE FROM YOIPR PAY? .. Y\ Ow M . a y ON AY = E THISIUMFIMIENV /�v-} •rr ; ODES YOU USE DATE OF LASS W;7RK DA B—ORE tr - v ,;fYti<AfiNfirJJ DATE •OU (. , Is e r AN.4J1 7HE AE*VF IS CORRECF TO THE REST OF MY KNMLEGG=—dP YEE S tcATURE DATE f J INSERVIEWSR SIGNAT13iF OR PRIN'eD NAME / DATE!YY11WDtD) W EaLPLa WAS=AhGWM ,UIN76LY; D )NTERV[EYVEEi'SCOPY19d-39TIS / ACT IOU IJF eagxYarua°a s naod°d am commons sccfnnJ YES NO rS EMPLOYEE PROPERLY CLASSMED AND PAID? ArG V,AGE RATES AND PaSTr,, 0tSPLAYED? FOR USE BY PAYROLL CHECKER YE WFORMATh7N IN AGFsEVZW Vl'I.H QAYROL L DATA? YES NO orACEMS ✓=FIEL:[E4 LAST NAME N MI JOBTITL£ S 9K.,r s 1i u L Sh,."1l'A RE DATE r ,NUDDJ AIDTI-30RIZE FOR CJ4i r7EPR- CT�DTc STANDARD FORM 1445 NEv.42-96)' Praxn-x d br�DSA-FAR-4S%FRJ 53.222ts} DB-0156 10/18/2010 Page 21 CDkFRAL"rNL•MBBR LABOR STANDARDS INTERVIEW TWDB Project ID: 72275 04--tOYEEINPIRMATION NAME GF MECDNfR4 O iAw; � F I"M /`Y� gull NA e — G I—TR 1S0 sss 4"' ERt?EOY^R SUPE� HeA S . 21P�to 'T NAME, ST NAM9 O� hU 7hf �tASStFI�TION 1.�4;ERATE SS ACTION! CHECK BELOW Do you work over 8 haetrs Per day?' YES NO Do you work over 40 hours Per week? A"a you Paid at least tirr s and a half for overtime hours? Are you receiving any cash payrsents jar fringe beriefits required by the posted wage determinatonu decision? t<Vf1AT i-'EDIi.^H1i,N$OTHER THiAN FAXESIROWMARY A7Ir7 SOCIAL S�CURtE'i ARE 8QAt1e?ROADS YOUR?AY." Oto OR ON YO TTHIS INi EMEWt O DATE OF LAST S1ISHRIC DAY SHEFORE"1TERVIEW.r ,ygnrtj D .,NO O j, S �. Yt(DD) PRPLDY THE ABOVE tS CORRCt 6 TD TtIE BEST OF PuHY KNOWLEC;E DATE, ) INTERYIE&M 5lGNA71SE 7Y?ED OR PRW-ED NAME I DATE{y}'�SQ,tly�� INTEMEWEA-S COMM WORC 961PLOWAS D,SSfItti E"E'N€0 - Ain,O V(Xf c:plam&ys i via-dad,rso cncamwrtr mclyon) Y65 NO r+EMPLOYEE PROPERLY CLASSSFD AND PAID? AR,€WAGE RA T ES 1S?JD PGST12RS fiGAILAYED' IS BOLE INPORMATiinY IN AGR£Ew7E1T1y'ITid?AYROLE'JA OR USE By PAYFIOLL GHEC9CER - YES NO rn .ENFS C14MKER STNAME FIR E 1,1f11 JOBFITL£ RE DATT!E//1/y� AL RI2EDp 6aHi iQPa "f l� Pro'isodt'cm o STANDARD F0Rm't44i466 tR tY-195t Pramru-d by SSA-TAP, CFRI 33-222fa1 DB-01S6 10/18/2010 Page 21