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HomeMy WebLinkAboutContract 57775-FP1-FP1 FORT WORTH. City Secretary Contract No. 57775 Date Received 07/24/2023 AT 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 complete: Project Name: Colonial Parkway Subdivision City Project No.: 103450 Improvement Type(s): x❑ Paving Original Contract Price: Amount of Approved Change Order(s): Revised Contract Amount: Total Cost of Work Complete: Val meza (Jul 12. 202 16:00 CDT) Contractor Prjct Mngr Title Concrete & Steel Structures, LLC Company Name J mes Ru (Jul 12. 202316:03 CDT) Project Inspector Vcto), V. ToMel'o,71:'PE. Project Manager Rebecca Diane Owen (Jul 24. 202311:32 CDT) CFA Manager I auren Prieur (Jul 24. 2023 12:42 CDT) TPW Director 1,th-4<�' Willi— Inhncnn Ili fDT) Asst. City Manager ❑x Drainage ❑ Street Lights ❑ Traffic Signals $146,462.00 -$10, 757.74 $135,704.26 $135,704.26 J u l 12, 2023 Date Jul 12, 2023 Date Jul 24, 2023 Date Jul 24, 2023 Date Jul 24, 2023 Date Jul 24, 2023 Date OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Page 1 of 2 Notice of Project Completion Project Name: Colonial Parkway Subdivision City Project No.: 103450 City's Attachments Final Pay Estimate ❑x Change Order(s): ❑x Yes ❑ N/A Contractor's Attachments Affidavit of Bills Paid Consent of Surety I Statement of Contract Time Contract Time 120 Days Charged: 119 Work Start Date: 10/3/2022 Work Complete Date 6/13/2023 Completed number of Soil Lab Test: 83 Completed number of Water Test: 0 Page 2of2 FORT WORTH CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name COLONIAL PARKWAY SUBDIVISION Contract Limits Project Type DRAINAGE & PAVING City Project Numbers 103450 DOE Number 3450 Estimate Number 1 Payment Number 1 For Period Ending 6/13/2023 WD City Secretary Contract Number Contract Time 12WD Contract Date 6/15/2022 Days Charged to Date 119 Project Manager NA Contract is 100.00 Complete Contractor CONCRETE & STEEL STRUCTURES 709 WYCHE BURLESON , TX 76028 Inspectors DEYON, G. / RUIZ Wednesday, July 5, 2023 Page 1 of 4 City Project Numbers 103450 Contract Name COLONIAL PARKWAY SUBDIVISION Contract Limits Project Type DRAINAGE & PAVING Project Funding UNIT III: DRAINAGE IMPROVEMENTS DOE Number 3450 Estimate Number 1 Payment Number 1 For Period Ending 6/13/2023 Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total 1 MEDIUM STONE RIPRAP GROUTED 75 SY $175.00 $13,125.00 75 $13,125.00 2 CONCRETE RIPRAP (CO #3) 35 SY $105.00 $3,675.00 35 $3,675.00 3 39" RCP CLASS III (CO #1) 0 LF $205.00 $0.00 0 $0.00 4 48" RCP CLASS 111 17 LF $405.00 $6,885.00 17 $6,885.00 5 TRENCH SAFETY 196 LF $10.00 $1,960.00 196 $1,960.00 6 6' STORM JUNCTION BOX 1 EA $6,500.00 $6,500.00 1 $6,500.00 7 6; DROP INLET 2 EA $8,500.00 $17,000.00 2 $17,000.00 8 48" PARALLEL HEADWALL 1 PIPE 1 EA $14,000.00 $14,000.00 1 $14,000.00 9 TURF REINFORCEMENT (CO #3) 80 SY $25.00 $2,000.00 80 $2,000.00 10 42" RCP, CLASS III (CO #1) 179 LF $342.00 $61,218.00 179 $61,218.00 Sub -Total of Previous Unit $126,363.00 $126,363.00 UNIT IV: PAVING IMPROVEMENTS Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total --------------------------------------- 1 REMOVE CONC CURB & GUTTER 94 LF $42.55 $3,999.70 94 $3,999.70 2 6" CONCRETE DRIVEWAY (CO #3) 0 SF $15.27 $0.00 0 $0.00 3 8" CONCRETE DRIVEWAY (CO #2) (CO #3) 0 SF $16.00 $0.00 0 $0.00 4 TOPSOIL 2 CY $45.05 $90.10 2 $90.10 5 BLOCK SOD PLACEMENT 9 SY $27.94 $251.46 9 $251.46 6 TRAFFIC CONTROL 1 MO $5,000.00 $5,000.00 1 $5,000.00 Sub -Total of Previous Unit $9,341.26 $9,341.26 Wednesday, July 5, 2023 Page 2 of 4 City Project Numbers 103450 Contract Name COLONIAL PARKWAY SUBDIVISION Contract Limits Project Type DRAINAGE & PAVING Project Funding Contract Information Summary Original Contract Amount Change Orders Change Order Number 1 Change Order Number 2 Change Order Number 3 Change Order Number 3 Total Contract Price DOE Number 3450 Estimate Number 1 Payment Number 1 For Period Ending 6/13/2023 $146,462.00 $24,523.00 $6,400.00 ($39,360.74) ($2,320.00) $135,704.26 Total Cost of Work Completed $135,704.26 Less % Retained $0.00 Net Earned $135,704.26 Earned This Period $135,704.26 Retainage This Period $0.00 Less Liquidated Damages Days @ / Day LessPavement Deficiency Less Penalty Less Previous Payment Plus Material on Hand Less 15% Balance Due This Payment $0.00 $0.00 $0.00 $0.00 $0.00 $135,704.26 Wednesday, July 5, 2023 Page 3 of 4 City Project Numbers 103450 DOE Number 3450 Contract Name COLONIAL PARKWAY SUBDIVISION Estimate Number 1 Contract Limits Payment Number 1 Project Type DRAINAGE & PAVING For Period Ending 6/13/2023 Project Funding Project Manager NA City Secretary Contract Number Inspectors DEYON, G. / RUIZ Contract Date 6/15/2022 Contractor CONCRETE & STEEL STRUCTURES Contract Time 120 WD 709 WYCHE Days Charged to Date 119 WD BURLESON, TX 76028 Contract is .000000 Complete CITY OF FORT WORTH SUMMARY OF CHARGES Line Fund Account Center Amount Gross Retainage Net Funded Total Cost of Work Completed $135,704.26 Less % Retained $0.00 Net Earned $135,704.26 Earned This Period $135,704.26 Retainage This Period $0.00 Less Liquidated Damages 0 Days @ $0.00 / Day $0.00 LessPavement Deficiency $0.00 Less Penalty $0.00 Less Previous Payment $0.00 Plus Material on Hand Less 15% $0.00 Balance Due This Payment $135,704.26 Wednesday, July 5, 2023 Page 4 of 4 PROJECT NAME: CONTRACT: CFA # CITY PROJECT # IPRC # FID # X FILE # FILE # INSPECTOR: PROJECT MANAGER: DEVELOPER -AWARDED -PROJECT CHANGE ORDER Colonial Parkway Subdivision Water, Sewer, Pavinq, Storm Drain CFA22-0077 103450 IPRC21-0154 30114-0200431-103450-EO7685 SD-0673 X-27154 CITY PARTICIPATION: NO James Ruiz Phone No: 817-392-8306 Victor V. Tomero Phone No: 817-392-7830 CONTRACT UNIT CHANGE ORDER No: 1 WATER SEWER PAVING DRAINAGE Developer Developer Developer D Cost City Cost Cost City Cost Cost City Cost Developer Cost City Cost C ORIGINAL CONTRACT $25,536.00 $82,037.00 I $42,302.00 $104,160.00 EXTRAS TO DATE I I I CREDITS TO DATE I I I CONTRACT TO DATE $25,536.00 $0.00 I $82,037.00 I S0.00 I $42,302.00 $0.00 I $104,160.00 $0.00 AMOUNT OF PROP. CHANGE ORDER LI $ 24,523.00 REVISED CONTRACT AMOUNT $25,536.00 50.00 $82,037.00 S0.00 I S42,302.00 I $0.00 I $128,683.00 I $0.00 TOTAL REVISED CONTRACT AMOUNT PER UNIT $25,536.00 $82,037.00 $42,302.00 $128,683.00 REVISED COST SHARE Dev. Cost: $278,558.00 City Cost: $0.00 TOTAL REVISED CONTRACT $278,558.00 STREET LIGHTS CONTRACT toper DAYS City Cost $0.00 1 1 120 S0.00 $0.00 i 120 $0.00 1 $0.00 I 120 $0.00 Revised: 10-12-2011 Page 1 You are directed to make the followina changes in the contract documents: CITY BID ITEM PAY ITEM : # QUANTITY UNIT 3 3341,0312 -179 LF 10 3341.0402 179 LF i REASONS FOR CHANGE ORDER Supplier issues w th 39"pipe TOTAL 3KCPtIass l III 42" RCP, Class III UNIT PRICE TOTAL $ 205.00 3 (36.695,00) s 342.00 S 61,218.00 $ 24,523.00 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. RECOMMENDED: `Y�+d ICrt APPROVED: hJJ//� APPROVED:-`� `✓' Y �F �` By: Paoe-Dawson Enolneers, Inc. By: Modular Manzi ement Group. Inc. By: Concrete & Steel Structures, LLC Name: Sam Kniqht Name: Name `t,NJ`J 1J ( lol r __ Title: Senior Project Manager Title: r �0 /0 Title: Yl LS G 0 �— Revised: 10-12-2011 Page 2 DEVELOPER -AWARDED -PROJECT CHANGE ORDER PROJECT NAME: Colonial Parkway Subdivision CONTRACT: Water, Sewer, Pavinq, Storm Drain CFA # CFA22-0077 CITY PROJECT# 103450 IPRC # IPRC21-0154 IFID # 30114-0200431-103450-EO7685 IX FILE # X-27154 I FILE # SD-0673 INSPECTOR: James Ruiz PROJECT MANAGER: Victor V. Tomero CITY PARTICIPATION: NO Phone No: 817-392-8306 Phone No: 817-392-7830 CHANGE ORDER No: 2 CONTRACT UNIT WATER SEWER PAVING DRAINAGE STREET LIGHTS Developer Developer Developer Developer Cost City Cost Cost City Cost Cost City Cost Developer Cost City Cost Cost city Cost ORIGINAL CONTRACT $25,536.00 $82,037.00 $42,302.00 $104,160.00 $0.00 EXTRAS TO DATE $24,523.00 ICREDITS TO DATE I ICONTRACT TO DATE I $25,536.00 $0.00 $82,037.00 $0.00 I $42,302.00 S0.00 $128,683.00 S0.00 $0.00 $0.00 (AMOUNT OF PROP. CHANGE ORDER I $ (1,782.00) I I I $ 6,400.00 (REVISED CONTRACT AMOUNT I $23,754.00 $0.00 I $82,037.00 I $0.00 I $48,702.00 S0.00 I $128,683.00 $0.00 I S0.00 $0.00 TOTAL REVIS AMOUNT I I I PER UN TCONTRACT $23 754.00 I $82,037.00 I $48,702.00 $128,683.00 $0.00 REVISED COST SHARE I Dev. Cost: $283,176.00 City Cost: $0.00 TOTAL REVISED CONTRACT I $283,176.00 CONTRACT DAYS 120 120 120 Revised: 10-12-2011 Page 1 You are directed to make the following changes in the contract documents CITY BID ITEM PAY ITEM QUANTITY UNIT Unit I: Water 1 3311.0001 -0.19 TON 4 3312.2103 -3 EA 5 3312.3002 -2 EA 7 9999.0001 2 EA 8" 33122003 3 EA Unit IV: Paving 3 Asterisk (-) indicates a New Pay Item REASONS FOR CHANGE ORDER 3213.0403 400 SF ]Ductile Iron Water Fittings w/Restraint 11 1/2" Water Service 16" Gate Valve 1 6" Spool Piece 11" Water Service 18" Concrete Driveway GRANDTOTAL Removal of proposed 6" fire line for sprinkler system. Extension of fire lane into site. ITEM DESCRIPTION UNITPRICE I TOTAL S 2,800.0015 (532.00) J S 2,500.00 $ (7,500.00) S 1.975.00 $ (3,950,00)� S 1.500.001 $ 3,000.00 $ 2.400.00 S 7,200.00 Total $ (1,782.00) S 16.00 S 6,400.001 Total S 6,400.00 I S 4,618.00 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. RECOMMENDED: By: Pape -Dawson Enqineers, Inc Name: Title: Vice -President APPROVED: By#dullar Manaa, e�c. Name: Title: V APPROVED: By: Concrete & Steel Structures, LLC Name:U\� Itp�eStd�� Title: \ Revised: 10-12-2011 Page 2 PROJECT NAME: I CONTRACT: I CFA # I CITY PROJECT # I IPRC # IFID# IX FILE # FILE # INSPECTOR: PROJECT MANAGER: ORIGINAL CONTRACT EXTRAS TO DATE ICREDITS TO DATE ICONTRACT TO DATE (AMOUNT OF PROP. CHANGE ORDER IREVISED CONTRACT AMOUNT TOTAL REVISED CONTRACT AMOUNT PER UNIT REVISED COST SHARE TOTAL REVISED CONTRACT DEVELOPER -AWARDED -PROJECT CHANGE ORDER Colonial Parkway Subdivision Water, Sewer, Pavinq, Storm Drain CFA22-0077 I 103450 IPRC21-0154 30114-0200431-103450-EO7685 X-27154 SD-0673 James Ruiz Victor V. Tomero CITY PARTICIPATION:( NO Phone No: 817-392-8306 Phone No: 817-392-7830 CHANGE ORDER No: 3 CONTRACT UNIT WATER SEWER PAVING DRAINAGE Developer Developer Developer Cost City Cost Cost City Cost Cost City Cost Developer Cost City Cost $25,536.00 $82,037.00 $42,302.00 $104,160.00 ($1,782.00) $6,400.00 $24,523.00 $23,754.00 $0.00 $82,037.00 $0.00 $48,702.00 S0.00 $128,683.00 $0.00 $ (39,360,74) $ (2,320.00) $23,754.00 $0.00 $82,037.00 $0.00 I $9,341.26 I $0.00 $126,363.00 $0.00 $23,754.00 I $82,037.00 I $9,341.26 I $126,363.00 STREET LIGHTS Developer Cost City Cost $0.00 Dev. Cost: $241,495.26 City Cost: $0.00 $241,495.26 I S0.00 $0.00 I I $0.00 I $0.00 $0.00 CONTRACT DAYS 120 120 120 Revised: 10-12-2011 Page 1 ff"ed to make the folklvnnq Chang in the CO You are dPAY CRY BID REM I I I REM' �mPntS I( I UNIT RF.M 11FSf_ RIPT1r1N UNIT PRICE TOTAL Uralll DraimOe 2 31370101 SY Ri..o S 10500 S (av COi 9 I 6001 99990002 f7 001 SY (Concrete Tirn ReinIorcemrd I S 25.00 S f1900001 Total 5 Unit N Pavino 2 3213 0401 (26200)I RF (lnnnmtn Drtvonnv S 15 27 : :a 0W '41 3 3213 0403 fi 810 no) I SF 16' 8" Rnnrmte INnrewnv S 16 00 i_8 990 00' -T...—,__ Toth f3296074) GRANDTOTAL J 136.290.74) Asterisk (') Indiabs a New Pay Rom REASONS FOR CHANGE ORDER Romovel o/ driveway pavomenf. Removal of drdmge Gems prrvatey maintained. 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. RECOMMENDED: ByP��a//ce' -QSon Enolneers. Inc Name QLa Title Project Manager Revised. 10-12.2011 APPROVED: By Modula-rj a�naaement Group. Inc APPROVED: By j�te�S 1 StrucTya LLC Name Title Page 2 FORTWORTH. M" TRANSPORTATION AND PUBLIC WORKS June 13, 2023 Concrete and Steel Structures, LLC 947 East Renfro St. Burelson, Tx 76028 RE: Acceptance Letter Project Name: Colonial Parkway Subdivision Project Type: Water, Sewer, Paving and Storm Drain City Project No.: 103450 To Whom It May Concern: On June 13, 2023 a final inspection was made on the subject project. There were punch list items identified at that time. The punch list items were completed on June 29, 2023. The final inspection and the corrected punch list items indicate that the work meets the City of Fort Worth specifications and is therefore accepted by the City. The warranty period will start on June 29, 2023, which is the date of the punch list completion and will extend of two (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 817-392-7830. Sincerely, Victor V Tornio 7;- T. U. Victor Tornero, Project Manager Cc: James Ruiz, Inspector Gary Deyon, Inspection Supervisor Edward Davila, Senior Inspector Victor Tornero, Program Manager Pape -Dawson, Consultant Concrete and Steel Structures,LLC, Contractor MMG Inc, Developer File E-Mail: TPW_Acceptance@fortworthtexas.gov Rev. 8/20/19 AFFIDAVIT STATE OF COUNTY OF Before me, the undersigned authority, a notary public in the state and county aforesaid, on this day personally appeared Name, Title Of Company, known to me to be a credible person, who being by me duly sworn, upon his oath deposed and said; That all persons, firms, associations, corporations, or other organizations furnishing labor and/or materials have been paid in full; That the wage scale established by the City Council in the City of Fort Worth has been paid in full; That there are no claims pending for personal injury and/or property damages; On Contract described as; Contract Description BY Name or Title Subscribed and sworn b fore me on this date Day of Month, Year. PAST I .......... N blic T 0e of . ty, State 4P* .'*` .......... 04-A 1 CONSENT OF SURETY COMPANY TO FINAL PAYMENT A/A DOCUMENT G707 OWNER ❑ ARCHITECT ❑ CONTRACTOR SURETY ❑ OTHER PROJECT: Colonial Parkway Subdivision (name, address) 2233 Colonial Pkwy Fort Worth, TX 76109 TO (Owner) F City of Fort Worth, TX 200 Texas Street Fort Worth, TX 76102 CONTRACTOR: Concrete & Steel Structures, LLC 709 Wyche Ct Burleson, TX 76028 Bond No. CE11729000039 ARCHITECT'S PROJECT NO: CONTRACT FOR: City Project No. 103450 J CONTRACT DATE: In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above, the (here insert name and address of Surety Company) Philadelphia Indemnity Insurance Company 2601 Market Place, Suite 300 SURETY COMPANY, Harrisburg, PA 17110 on bond of (here Insert name and address of Contractor) Concrete & Steel Structures, LLC 709 Wyche Ct CONTRACTOR, Burleson, TX 76028 hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall not relieve the Surety Company of any of its obligations to (here insert name and address of Owner) City of Fort Worth, TX 200 Texas Street OWNER, Fort Worth, TX 76102 as set forth in the said Surety Company's bond. IN WITNESS WHEREOF, the Surety Company has hereunto set its hand this 10th day of July XX2023 Philadelphia Indemnity_ Insurance Company,-,'. ","' - =.Q Surety Com" s : Signature of Authorized Representative Attest: (seal): Esteban Flores, Attorney -in -Fact Title �fr= 1 I CAUTION: You should sign an original AIA document which has this caution printed in red. An original assures that changes will not be obscured as may occur when documents are reproduced. 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 WARNING: Unlicensed photocopying violates U.S. copyright laws and is subject to legal prosecution. Bond # CEl 1729000039 PHILADELPHIA INDEMNITY INSURANCE COMPANY One Bala Plaza Suite 100 Bala Cynwyd, PA 19004-0950 Power of Attorney KNOW ALL PERSONS BY THESE PRESENTS: That PHILADELPHIA INDEMNITY INSURANCE COMPANY (the Company), a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, does hereby constitute and appoint Michael D. Lrurre. Deborah M. McQcNa. Colleen Watson, Kevin Pt Shiite. Phi & Simons. Yvonne Weatherford. Jonen A. Marx Brad Ulerdleck. Bernardo C Scorza Gaspar, Matt Bor dare. Brian D. Russell Jr.. Robert J. H_1 at0&w.. ArAw Jolgtson. Mark Karr. Eslehan Dares. ate. M. Friedlk ofNFP Proaem, &CasaaltvSenices lite its true and lawful Attorney -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 SS0.000.000. This Power of Attorney 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 on the 14"' of November, 2016. RESOLVED: That the Board of Directors hereby authorizes the President or any Vice President of the Company: (1) Appoint Attomey(s) in Fact and authorize the Attomey(s) in Fact to execute on behalf of the Company bonds and undertakings, contracts of indemnity and other writings obligatory in the nature thereof and to attach the seal of the Company thereto; and (2) to remove, at anytime, any such Attomey-in-Fact and revoke the authority given. And, be it FURTHER RESOLVED: That the signatures of such officers and the seal of the Company may be affixed to any such Power of Attorney or certificate relating thereto by &simile, and any such Power of Attorney so executed and certified by ficsimile signatures and ficsimile seal shall be valid and binding upon the Company in the fixture with respect to any bond or undertaking to which it is attached. 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 5TH DAY OF MARCH, 2021. 927 # (Seal) ., krh Clomp, President CEO Philadelphia Indemnity Insurance Company On this 51h day of March, 2021 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 therein described and authorized officer of the PHILADELPHIA INDEMNITY INSURANCE COMPANY; that the seal affixed to said instrument is the Corporate seal of said Company; that the said Corporate Seal and his signature were duly affixed. Gflmmomrs4h c1Pennayw4ny •hoary 5rrat Vanessa Mckenzie. NotaryPubik: Montgomery County My commtsWon expires November 3.2024 Commission number 1366324 Mvmv4,. Parnryt- • A11aC14tk0n V N*1Ar41 Notary Public: c residing at: Bala Cynwyd, PA My commission expires: November 3.2024 I, Edward Sayago, Corporate Secretary of PHILADELPHIA INDEMNITY INSURANCE COMPANY, do hereby certify that the foregoing resolution of the Board of Directors and the Power ofAttorney issued pursuant thereto on the 5" day March, 2021 are true and correct and are still in full force and el%ct. I do further certify that John Glomb, who executed the Power of Attorney as President, was on the date of execution of the attached Power of Attorney the duly elected President of PHILADELPHIA INDEMNITY INSURANCE COMPANY. In Testimony Whereof Ihave subscribed my name and affixed the facsimile seal of each Company this 10th day of July 2023 1927 Edward Sayago, Corporate Secretary PHILADELPHIA INDEMNITY INSURANCE COMPANY CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Ventura On 07/10/2023 before me, R. M. Friedik (Here insert name and title of the officer) personally appeared Esteban Flores , Notary Public, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. QPMyComm. R. MFRIEDIK WITNESS my h d and I seal. Notary Public - California Ventura County f Commission 9 2387569 Expfres Dec 19, 20251 Signature of Notary ubhc (Notary Seal) i y ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT Bond No. CE11729000039 (Title or description of attached document) N/A (Title or description of attached document continued) Number of Pages two Document Date 07/10/2023 N/A (Additional information) CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) ❑ Corporate Officer (Title) ❑ Partner(s) ✓❑ Attorney -in -Fact ❑ Trustee(s) ❑ Other INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California must contain verbiage exactly as appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is if a document is to be recorded outside of California. 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