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CITY OF FORT WORTH
NOTICE OF PROJECT COMPLETION
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Regarding Contract Number 46445 for the Meadowbrook Elevated Storaee Tank Rehabilitation Project
which was requested by the Water Department and approved by City Council on January 6, 2015 through
M&C C-27145, has been accepted by the Director of the Water Department as complete.
Original Contract Price: $ 968,800.00
Amount of Approved Change Orders $ 0.00 Number One
Revised Contract Amount:
Total Cost Work Completed:
Less Liquidated Damages:
Less Pavement Deficiencies:
Less Penalty:
Total Contract Cost:
Less Previous Payments:
Final Payment Due:
$ 968,800.00
$ 953,000.00
$ 0.00 (Day 0 @ $ 500.00
$ 0.00
$ 0.00
$ 953,000.00
$ 905,350.00
$ 47,650.00
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Recommended: Andrew T. Cronber . P. . ate
Asst. D'u•ector, Wa er D arhnent
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Approved Jesus J. Chapa
Assistant City Manager
EllYA1fLED
OCT � 1 �91�
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AFFIDAVIT OF BII,LS PAID
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STATE OF ���
COUNTY ��J l «��
Before me, the undersigned authority, personally appeared ANTONIO BANDA
the PRESIDENT of A&M CONSTRUCTION AND UTILITIES INC, who upon his/her
oath deposed and said:
On City of Fort Worth Contract described as:
MEADOWBROOK ELEVATED STORAGE TANK REHABILITATION
PROJECT
All persons, firms, associations, corporations, or other organizations furnishing
labor and/or materials have been paid in full all amounts due and owing as of this date
except for those noted on the attached schedule. Any unpaid future obligations will be
paid and satisfied directly out of funds paid in reliance on this aiiidavit; and
The wage scale established by the City Council in the City of Fort Worth has been
paid in full; and
There are no claims pending for personal injury and/or property damages.
All of the provisions of this release shall bind the A&M CONSTRUCTION AND
UTILITIES, INC and its legal representatives, successors and assigns and shall inure to
the benefit of the City.
The person signing this document represents that he/she is duly authorized to do
so on behalf of A&M CONSTRUCTION AND UTILITIES IN.
By: l�t '��C -
Name: � � - s�-, �.1�
Title: i 2E-� �f �,.��
S- SCRIB � �S ORN TO AND_ ACKNO� GED BEFORE ME by
, � `�� "" � h /�- on this the �� day of �JC �� �r �- , 20 /S�to certify
hich w' ne my hand and official seal of office.
c, State of Texas
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%'ii,�2017.....••'`\\\\��
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My commission expires:
SCHEDULE OF UNPAID AMOUNTS
Contractor/Vendor Name: Amount Paid Amount Owed Percentage Owed
�� �� �� $ $ %
� $ %
$ $ °/a
$ $ %
$ $ %
$ $ %
$ $ %
$ $ %
If all contractors/vendors have been paid in full and there are no pending or known
claims, write NONE on the first line.
CONSENT OF SURETY
TO FINAL PAYMENT
AIA Document G707
(Insti-uctions on reverse side)
TO OWNER:
(Namc and addicssJ
City of Fort Worth
1000 Throckmorton Street
Fort Worth, TX 76102
PROJECT:
(Namc and addressJ
Meadowbrook Elevated
Project No. 02329
Tank Rehabilitation
gp� #; PB01682800148
OWNER
ARCHITECT
CONTRACTOR
SURE1'Y
OTHER
ARCHITECT'S PROJECT NO.:
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■.
■
■
■
CONTRACT FOR:
CONTRACT DATED: 7anuary 7, 2015
In accordance with [he provisions of the Contract between the Owner and the Contractor as indicated above, the
(Insert name and address of Surety)
Philadelphia lndemnity Insurance Company
One Bala Plaza, Suite 100
Bala Cynwyd, PA 19004
, SUx$'rY,
on bond of
(Inse�� name und address ojContractar)
A&M Construction and Utilties, Inc
4950 Grisham Drive
Rowlett. TX 75088
,CONTRACTOR,
hereby approves of the final payment to the Contracror, and agrees that final payment to the Contractor shall not relieve the Surery of
any of its obligations to
pnser� name and addreas ofOwnerJ
City of Fort Worth
1000 Throckmorton Street
Fort Worth, TX 76102
as set forth in said Surety's bond,
, OWNER,
IN WITNESS WHEREOF, the Surety has hereunto set its hand on this date: October 14 , 2 015
(lnser� in wriiing �he mamhJollowed by the numeric date and year)
Philadelphia lndemnity Insurance Company
rs��.e� � -
� i ojwi ized re m e) ---
Attest:
(Seal): Brent M. Blonigan, Attorney-In-Fact
(P�inted name and tltle)
""�`"� ��l�"ift'J.� �ras� �t�a€�td �6g�e� ,�€� s��i€�i;��l ,�,6Fs c�e�cc�n�ar�� fi4rt�z� I�as ti�€� cas��i�sn �Sri��tes� ir� rw�. ��
��R°-��=° � ,
���. �� �arir�in�i a�w:�r�e� tl�Q# ch����€�s ddill rsc�� C�e cst� ,�ur�:cf a: i��y ocaur �����n c€�c�€tne€�*s ar� re�rac�uced.
�x:� ��,=,ja wee l��.�t�ucti+��t 5heei i€�r �.iani�eci Lic�r��e €"c�r� E"te��ERc�r�uciroEr esf fit��s dcacu��t�r��,
AIA DOCUMENT G707 - CONSEM' OF SURECY TO PINA[. PAYMEAfI'- 1994 EDITION -NA Page 1 of 2
1994 -1'HE AIvSQIICAN INS7'IT[TCE OF ARCFiITECTS, 1735 NEW YORK AViNUE, NW, WASH-
INGTON, D.C.2ao06-5292 - WARNING: Unlfeensed photocopying violates U.S. aopy- G%07-1994
rl8ht laws and wtll aubJeet the vlolatorlo Iepai prosecution.
INSTRUCTION SHEET
FOR AIA DOCLJMENT G7a7, CONSENT OF SURETY TO FINAL PAYMENT
A. GENERAL INFORMATION
1.Purpose
This document is intended for use as a companion to AIA Document G706, Contractor's Affidavit of Payment of Debts and
Claims, on conshuction projects where the Conh'actor is required to fumish a bond. By obtaining the Surety's approval of final
payment to the Contractor and its agreement that final payment will noY relieve the Surety of any of its obligations, the Owner
may preserve its rights under the bond.
2. Related Documents
This document may be used with most of ihe AIA's Owner-Contractor agreements and general conditions, such as A201 and its
related family of documents. As noted above, this is a companion document to AIA Document G706.
3. Use of Current Documents
Prior to using any AIA document, the user should consult the AIA, an AIA component chapter or a current AIA Documents List to
determine the current edition of each document.
4. Limited License for Reproduction
AIA Document G707 is a copyrighted work and may not be reproduced or excerpted from in substantial part without the express
written permission of the AIA. The G707 document is intended to be used as a consumable-that is, the original document pur-
chased by the user is intended to be consumed in the course of being used. There is no implied permission to reproduce this
document, nor does membership in The American Institute of Architects confer any fiuther rights ta reproduce G�07.
A cautionary notice is pr9nted in red on the original of tliis document. This notice disfinguishes an original AIA document from
copies and counterfeits. To ensure accuracy and uniformity of language, purchasers should use only an original AIA document or
one that has been reproduced from an original under a speciai limited license from the AIA.
A limited license is hereby granted to retail purchasers to reproduce a maximum of ten copies of a completed or executed G707, but
only for use in connection with a particular project. Further reproducrions are prohibited without the express permission ofthe AIA.
B. CHANGES FROM THE PREVIOUS EDITION
Changes in the location of various items of information were made, without revision to the substance of the document.
C. COMPLETING THE G707 FORM
GENERAL: The bond form is the usual source of required information such as the contract date and the names and addresses of the
5wety, Owner, Contractor and Project.
ARCHITECT'S PRO7ECT NO.: this information is typicaily supplied by the Architect and entered on the form by the Contractor.
CONTRACT FOR: This refers to the scope ofthe contract, such as "General Construction" or "Mechanical Work".
D. EXECUTION OF THE DOCUMENT
The G707 form requires both the Surety's seal and the signature of the Surety's authorized representative.
4/94
INS'I'RUCTION SHEET FOR AIA DOCU71iF.NT G707 OCONSENT OF SURETY TO FINAL PAYMENT � 1994
EDTTION�AIA�_THE AMERICAN INSTITUTE OP ARCHITECTS, 1735 NEW YpRK AVENUE, N.W.,
WASHINGTON, D.C. 2000G-5292
Page 2 of 2
G707-1994
1243
PHILADELPHIA WDEMNITY INSURANC� COAZPANY
One Bala Plaza. Suite ]00
Bala Cynwyd, PA 19004
Power of Attorney
KNOW ALL PERSONS BY THESE PRESENTS: that PHILADELPHIA INDEMNITY INSURANCE COMPANY (the Company), a corporation oreanized and
existin� under the laws of the Commomvealth of Pennsylvania, does hereby constilute and appoint: Raul F. Campa, Debbie Palmer, Kara Pierce and Brent M.
Blonigan of Grayhawk Insurance Associates of Richardson, TX.
Its we and lawful Attomey(s) in fact with full authority to execute on its behalf bonds, undertakings, recognizances and other contracts of indemnity and writings
obligatory in the nature thereof, issued in the course of its business and to bind the Company thereby, in an amount not to exceed $25,000.000
'Ihis Power of Attomey is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of
PHILADELPHiA INDEMNITY INSURANCE COMPANY at a meeting duly called the 1" day of July, 2011.
RESOLVED: That the Board of Directors hereby authorizes the President or any Vice President of the
Company to: (1) Appoint Attorney(s) in Fact and authorize the Attorney(s) in Fact to
execute on behalf of the Company bonds and undertakings, convacts of indemniry and
other writings obli¢arory in the nature thereof and to attach the seal of the Company
thereto: and (2) to remove, at any time, any such Attomey-in-Fact and revoke the
authoriry given. Md, be it
FURTH�R
RESOLVED: That the signatures of such o�cers and the seal of the Company may be affuced to any
such Power of Atromey or certificate relating thereto by facsimile, and any such Power of
Attomey so executed and certified by facsimile signatures and facsimile seal shatl be
valid and biding upon the Company in the future with d�e respect to any bond or
undertal:ing to which it is auached.
IN TESTIMONY WHEREOF, PHILADELPHIA INDEMNITY INSURANCE COMPANY HAS CAUSED THIS INSTRUMENT TO BE SIGNED AND
ITS CORPORATE SEALTO BE AFFIXED BY ITS AUTHORIZED OFFICE THIS 7TF� DAY OF FEBRUARY 2013.
��.f�f�2,�,
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(Se3l) - •
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Robert D. O'Leary Jr., President & CEO
Philadelphia lndemnity Insurance Company
On tliis 7'� day of February 2013, before me came the individual who executed the preceding instrument, to me personally known, and being by me duly swom said that
he is the [herein described and au[horized officer of the PHILADELPHIA INDEMNITY INSURANCE COMPANY; that the seal affixed ro said instrument is the
Corporate seal of said Company; that the said Corporate Seal and his signature were duly affixed.
eontn�onweai.ni oFPrawsr�uu�w.
NOTARIAtSEAL
DANIELLE PORATH, Nuiary Pubec
Low2rMedonTw .,Monmom COunty
(bmmfssian ' Mardi�ZOt6
Notary Public:
residing at:
(Notary Seal)
My commission expires:
/ �/��" "`� "` �
Bala Cvmwd. PA
l, Craig P. Keller, Executive Vice President, Chief Financial Officer and Secretary of PHILADELPHIA INDEMNITY INSURANCE COMPANY, do herby certify that
the foregoing resolution of the Board of Directors and this Power of Attomey issued pursuant d�ereto are we and correct and are stitl in full force and effect. I do
further certify that Robert D. O'Leary Jr., who executed the Power of Atrorney as President, was on the date of execution of the attached Power of Attomey the duly
elected President of PH[LADELPHIA INDEMNITY INSURANCE COMPANY, � �
In Testimony \Vliereof I have subscribed my name and affixed the facsimile seal of each Company this 1 I day of . 20�
r,, `,
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Craig P. Keller, Executive Vice President, Chief Financial Officer & Secretary
PHILAD�LPHIA INDEI4INITY INSURANCE COMPANY
IMPQF2TANT NOTECE
To obtain information or rnake a complaint: You may
call the Surety's tofl free telephone number for
information or to make a complaint at:
1-877-438-7459
You may also write Philadelphia lndemnity Insurance
Campany at:
C3ne Bala Ptaza, Suite 100
Bala Cynwyd, PA 19004
Aitention: Sen€or Vice Presidenf and
Director af Surety
You may contact fhe Texas Department of Insurance
to obtain infarmation on cornpanies, coverage, rights
or complaints at:
1-800-252-3439
You may write the Texas Department of insurance
at:
P,Q. Box 949104
Austin, TX 78714-9104
Fax# 512-475-1771
Web: http://wuvw.�cfi.siate.tx.us
Email: GonsumerFrotectionCc�?tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES: Should you have
a dispute concerning you� premium or about a claim,
you should contact the Sureiy first. {f the dispuie is
not resolved, you may contact the Texas Deparkment
of Insurance.
AifACH THIS NOTICE TO YOUR BOND: This
notice is for informafion only and does not become a
part or condition of the attached document.
ADVISO ItJIPORTANTE
Para obener informacion o para someter una queja:
Usted puede Ilamar al numero de telefono gratis de
para informacion o para someter una queja al:
1-877-438-7459
Usted tanbien puede escribir a Philadelphia
Indemnity Insurance Company:
One Ba{a R[aza, Suite 100
Bala Cynwyd, PA 19004
AiEention: Seniar Vice Presicient and
Qirector of Sureiy
Puede comunicarse con el Departamento de
Seguros de Texas para obtener informacion acerca
de companias, coberturas, derechos o quejas al:
1-SOp-252-3439
Puede escribir al Departmento de Seguros de Texas:
P.O. Box 149104
Ausiin, TX 78714-8104
Fax# 512-475-1771
Web: http;/luvww.tdi.sta#e.t�c.us
Emaii: Gonsu�nerPratecfiianC�tdi.state.t,�.us
DISPUTAS SOBRE PRIMAS 0 RECLAMOS: Si
tiene una dispufa concemiente a su prima o a un
reclamo, debe comunicarse con el Surety primero. Si
no se resuelve la disputa, puede entonces
comunicarrse con ei departamento (TDI).
UNA ESTE AVISO A SU FIANZA DE GARANTIA:
Este aviso es solo para proposito de informacion y
no se convie�te en parte o condicion del documento
adjunto.