HomeMy WebLinkAboutContract 57087-FP2-FP2
FORT WORTH.
City Secretary
Contract No. 57087
Date Received 10/20/2023
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: Wayfare Multifamily Cibolo Hills Parkway
City Project No.: 103516
Improvement Type(s): Water x❑ Sewer x❑
Original Contract Price: Water
Original Contract Price: Sewer
Original Contract Price: Total
Amount of Approved Change Order(s)
Revised Contract Amount:
Total Cost of Work Complete:
W KPith Tangs
W. Keith Jones (Oct 20. 2023 13:12 CDT)
Contractor
President
Title
IMS Construction
Company Name
x ,Auus�
Adrian Aranda(Oct 20. 202313:14 CDT)
Project Inspector
Project Manager
Rebecca Diane Owen fOct 20. 2023 15:07 CDT)
CFA Manager
Lauren Prieur
TPW Director
William Johnsoq,02j4-20-2-3-14:16 CDT)
Asst. City Manager
Developer
$495,729.42
$165,850.39
$661,579.81
$87,570.00
$ 749,149.81
$749,149.81
City
$148,017.70
$0.00
$148,017.70
$0.00
$148,017.70
$148,017.70
Oct 20, 2023
Date
Oct 20, 2023
Date
Oct 20, 2023
Date
Oct 20, 2023
Date
Oct 20, 2023
Date
Oct 24, 2023
Date
Total
$643,747.12
$165,850.39
$809,597.51
$87,570.00
$897,167.51
$897,167.51
AT
OFFICIAL RECORD
CITY SECRETARY Page 1 of 2
FT. WORTH, TX
Notice of Project Completion
Project Name: Wayfare Multifamily Cibolo Hills Parkway
City Project No.: 103516
City's Attachments
Final Pay Estimate x❑
Change Order(s): ❑x Yes ❑ N/A
Pipe Report: x❑ Yes ❑ N/A
Contractor's Attachments
Affidavit of Bills Paid,,
Consent of Surety
Statement of Contract Time
Contract Time: 120 WD
Work Start Date: 3/21 /2022
Completed number of Soil Lab Test: 573
Completed number of Water Test: 23
Days Charged: 293
Work Complete Date: 9/15/2023
Page 2 of 2
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name WAYFARE MULTIFAMILY (CIBOLO HILLS PARKWAY)
Contract Limits
Project Type WATER & SEWER
City Project Numbers 103516
DOE Number 3516
Estimate Number 1 Payment Number 1 For Period Ending 9/15/2023
WD
City Secretary Contract Number Contract Time 12WD
Contract Date 12/6/2021 Days Charged to Date 293
Project Manager NA Contract is 100.00 Complete
Contractor IMS CONSTRUCTION
5690 WATERMELON ROAD, SUITE 400
NORTHPORT , AL 35473
Inspectors D. WATSON / A. ARANDA
Friday, September 22, 2023 Page 1 of 5
City Project Numbers 103516 DOE Number 3516
Contract Name WAYFARE MULTIFAMILY (CIBOLO HILLS PARKWAY) Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER & SEWER For Period Ending 9/15/2023
Project Funding
UNIT 1A: WATER IMPROVEMENTS CITY DEVELOPER
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
---------------------------------------
1
16" PRESSURE PLUG
1 LF
$1,000.00
$1,000.00
1
$1,000.00
2
4"-12" PRESSURE PLUG
2 TN
$1,153.26
$2,306.52
2
$2,306.52
3
TRENCH SAFETY (CO #1)
3037 LF
$1.00
$3,037.00
3037
$3,037.00
4
IMPORTED EMBEDMENTBACKFILL CSS
1.1 LF
$87.02
$95.72
1.1
$95.72
5
DUCTILE IRON WATER FITTING W/RESTRAINT
3.13 EA
$4,750.00
$14,867.50
3.13
$14,867.50
6
8" PVC WATER LINE
84 EA
$50.00
$4,200.00
84
$4,200.00
7
12" PVC WATER PIPE
110 EA
$70.00
$7,700.00
110
$7,700.00
8
16" DIP WATER CLSM BACKFILL
81 EA
$150.00
$12,150.00
81
$12,150.00
9
16" PVC C905 WATER PIPE
2642 EA
$115.50
$305,151.00
2642
$305,151.00
10
FIRE HYDRANT
1 EA
$3,480.00
$3,480.00
1
$3,480.00
11
2" COMBINATION AIR VALVE ASSEMBLY FOR
2 EA
$10,500.00
$21,000.00
2
$21,000.00
WATER
12
8" WATER METER AND VALVE
2 EA
$27,202.67
$54,405.34
2
$54,405.34
13
8" GATE VALVE
2 EA
$1,850.00
$3,700.00
2
$3,700.00
14
IT GATE VALVE
2 EA
$2,100.00
$4,200.00
2
$4,200.00
15
16" GATE VALVE W/VAULT
5 EA
$20,544.00
$102,720.00
5
$102,720.00
16
36"X16" TAPPING SLEEVE & VALVE
1 EA
$35,350.00
$35,350.00
1
$35,350.00
17
6" BLOW OFF VALVE
1 EA
$23,500.00
$23,500.00
1
$23,500.00
18
--------------------------------------
2" WATER SERVICE (CO #1)
3 EA
$4,350.00
$13,050.00
3
$13,050.00
Sub-Total of Previous Unit
$611,913.08
$611,913.08
UNIT 113: WATER IMPROVEMENTS 100%CITY COST
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
---------------------------------------
1
CONC PVMT REPAIR, ARTERIAL/INDUSTRIAL
52 SY
$105.02
$5,461.04
52
$5,461.04
2
8" PVC WATER LINE
673 LF
$50.00
$33,650.00
673
$33,650.00
3
TRENCH SAFETY
673 LF
$1.00
$673.00
673
$673.00
4
8" GATE VALVE
2 EA
$1,850.00
$3,700.00
2
$3,700.00
5
DUCTILE IRON WATER FITTINGSW/
0.32 TN
$4,750.00
$1,520.00
0.32
$1,520.00
--------------------------------------
RESTRAINT
Sub-Total of Previous Unit
$45,004.04
$45,004.04
Friday, September 22, 2023 Page 2 of 5
City Project Numbers 103516 DOE Number 3516
Contract Name WAYFARE MULTIFAMILY (CIBOLO HILLS PARKWAY) Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER & SEWER For Period Ending 9/15/2023
Project Funding
UNIT H: SANITARY SEWER IMPROVEMENTS
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
---------------------------------------
1
LARGE STONE RIPRAP, DRY
378 SY
$135.00
$51,030.00
378
$51,030.00
2
POST CONSTRUCTION CCTV
855 LF
$2.00
$1,710.00
855
$1,710.00
3
MANHOLE VACUUM TESTING
6 EA
$174.87
$1,049.22
6
$1,049.22
4
TRENCH SAFETY
855 LF
$1.00
$855.00
855
$855.00
5
CONCRETE COLLAR
6 EA
$479.92
$2,879.52
6
$2,879.52
6
6" SEWER SERVICE
1 EA
$280.00
$280.00
1
$280.00
7
12" SEWER PIPE
570 LF
$55.00
$31,350.00
570
$31,350.00
8
12" DIP SEWER
285 LF
$150.69
$42,946.65
285
$42,946.65
9
4' MANHOLE
6 EA
$4,650.00
$27,900.00
6
$27,900.00
10
4' EXTRA DEPTH MANHOLE
26 VF
$225.00
$5,850.00
26
$5,850.00
11
24" CASING BY OTHER THAN OPEN CUT (CO
160 LF
$465.00
$74,400.00
160
$74,400.00
#1)
Sub -Total of Previous
Unit
$240,250.39
$240,250.39
Friday, September 22, 2023 Page 3 of 5
City Project Numbers 103516
Contract Name WAYFARE MULTIFAMILY (CIBOLO HILLS PARKWAY)
Contract Limits
Project Type WATER & SEWER
Project Funding
Contract Information Summary
Original Contract Amount
Change Orders
Change Order Number 1
Change Order Number 1
Total Contract Price
DOE Number 3516
Estimate Number 1
Payment Number 1
For Period Ending 9/15/2023
$809,597.51
$13,170.00
$74,400.00
$897,167.51
Total Cost of Work Completed $897,167.51
Less % Retained $0.00
Net Earned $897,167.51
Earned This Period $897,167.51
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
$897,167.51
Friday, September 22, 2023 Page 4 of 5
City Project Numbers 103516
Contract Name WAYFARE MULTIFAMILY (CIBOLO HILLS PARKWAY)
Contract Limits
Project Type WATER & SEWER
Project Funding
Project Manager NA
Inspectors D. WATSON / A. ARANDA
Contractor IMS CONSTRUCTION
5690 WATERMELON ROAD, SUITE 400
NORTHPORT, AL 35473
DOE Number 3516
Estimate Number 1
Payment Number 1
For Period Ending 9/15/2023
City Secretary Contract Number
Contract Date
12/6/2021
Contract Time
120 WD
Days Charged to Date
293 WD
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 $897,167.51
Less % Retained
$0.00
Net Earned
$897,167.51
Earned This Period $897,167.51
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
$897,167.51
Friday, September 22, 2023 Page 5 of 5
DEVELOPER -AWARDED -PROJECT CHANGE ORDER
(PROJECT NAME: Wavfare Multifamilv CHANGE
ICONTRACT: CS 57087 ORDER No:
ICFA# 21-0104 I CITY PARTICIPATION:( Yes CSC No.57087-CO1
ICITY PROJECT # 103516 1
IFID # 30114-0200431-103516-EO7685
IFILE # X-27026, W-2790
INSPECTOR:
Jesse Davis
Phone No:
817-863-3705
PROJECT MANAGER:
Debbie Willhelm
Phone No:
817-392-2481
CONTRACT UNIT
I
WATER
SEWER
PAVING
DRAINAGE
STREET LIGHTS & SIGNS I
CONTRACT
Developer
Developer
Developer
Developer
=
DAYS
Cost
City Cost
Developer Cost
City Cost
Cost
City Cost
Cost
City Cost
Cost
City Cost
IORIGINAL CONTRACT
$495,729.42
$148,017.70
$165,850.39
$0.00
$1,161,361.58
$0.00
$575,207.36
$0.00
$167,755.75
$0.00
120
I EXTRAS TO DATE
ICREDITS TO DATE
ICONTRACT TO DATE
$495,729.42
$148,017.70
$165,850.39
$0.00
$1,161,361.58
$0.00
$575,207.36
$0.00
$167,755.75
$0.00
120
(AAMM�/O`UUNNpT`Orr/F PROP.C/HHAAry1N�GE ORDER
$13,170.00
$0.00
$74,400.00
$0.00
$0.00
$0.00
$41,634.00
$0.00
$0.00
$0.00
0
$508,899.42
$148,017.70
$240,250.39
$0.00
$1,161,361.58
$0.00
$616,841.36
$0.00
$167,755.75
$0.00
120
TOTAL REVISED GONTHACT AMOUNT
PER UNIT
$656,917.12
$240,250.39
$1,161,361.68
$616,841.36
$167,765.75
REVISED COST SHARE
Dev. Cost:
$2,695,108.50
City Cost:
$148,017.70
TOTAL REVISED CONTRACT
$2,843,126.20
Revised 10-12-2011 Page 1
You are directed to make the following
ehani in the fl c ntract docu ema
rgll
CITY BID ITEM If
PAY ITEM #
# I QUANTITY I UNIT l ITEM DESCRIPTION
UNIT PRICE Developer Cost
City Cost
UNITIA-]NATEIj IMPROVEMENT (CITY -DEVELOPER COST SHARE)
I
I NEW
3312.2203 3 I EA 2"Water Service
$4,350.00 Yv13.050.00
�0:00 I
I 3
I 3305.0109 120 I LF Trench Safety
I
$1.00 120.00
$tj 00 I
I
Subtotal Unit [A -Water Improvements (City -Developer Cost Share)
$13,170.00
$0.00 I
You are directed to make the following c anges in
BID ITEM thecontract documents
IPAY ITEM # # QUANTITY I UNIT I I UNIT I([[[ -SEWER
I NEW I 3305.1104 I 160 I LF
I
ITEM DESCRIPTION UNIT PRICE Developer Cast City Cost
I
24" Casing by Other Than Open Cut $465.00 $74 400.Co $0.00 I
Subtotal Unit II Sanitary Sewer Improvements $74,�00.00 $0.00 I
You are directed to make the following changes in the cPntract docu�Illents
I CITY BID ITEM
PAY ITEM #
I QUANTITY I UNIT
ITEM DESCRIPTION UNIT PRICE Developer Cost
City Cost
UNIT III-DRAINAG IMPROVEMENTS
I
I 3
3137.0102
5
SY
Large Stone Ripmp, dry $90.00 $450.00
$0.00 I
I 4
3305.010',
234
LF
Trench Safety $1.00 $234.00
$0.00 I
I 10
3341.0402
234
LF
42" RCP, Class III $175.00 $40.950.00
$0.00 I
I
Subtotal Unit III - Drainage Improvements $41,634.00
$0.00 I
GRAND TOTALI I$128,204.00 I
$0.00 I
Asterisk (") indicates New Pay Item
REASONS FOR CHANGE ORDER
Portion of the sanitary sewer under private parking lot will be installed by
bore. Added irrigation services to private development. Extend storm pipe to provide cover
for water line. Changes correspond to Plan Revision 02, 03, and 04 as shown on Sheets 8, 10, 11, 12, 17, 18, 20, 35, 37, 40, and 46 of the construction plans. No
additional days are requested for this change order.
This project has City Participation. This change order does not affect City Participation. Developer is responsible for 100 % of the change order cost and no
reimbursement from the City will be sought by the Developer.
[SIGNATURES APPEAR ON THE FOLLOWING PAGE]
Revised 10-12-2011 Page 2
F d.MLaEdSolutions
Amanda Mafa
By Amanda —.(Apr I7,202309 Do CDT)
Name: Amanda Mats, PE
Title Project Manager
APPROVAL RECOMMENDED:
CFW - Water Department
By i
Name Taylor Gunderman, PE
Title: Enqineerinq Manaqer
RECOMMENDED:
CFW - *Contrect Compliance Manager
By: 9
Name: Debbie J. Willhelm, PE
Title Senior Professional Engineer
M&C Number: M&C21-0769
M&C Date Approved 9/28/2021
APPROVED:
Wayfare Development Group- Cibolo Hills, LLC
By x1.3gu„ ....as o.IDT)
Name: Jackson Wallace
Title President & CEO
APPROVED:
CFW - Assistant City Manager
By .171
Name: Dana Burghdoff
Title: Assistant City Manager
APPROVED:
IMS Construction,�ny{'�
By keiU, 3Js'r'}Ic iI IrT)
Name: Keith Jones
Title President
APPROVED AS TO FORM AND LEGALITY:
CFW - Assistant City Attorney
Name: Richard McCracken
Title: Semor Assistant City Attorney
ATTEST
* Contract Compliance Manager (Project Manager):
A�
By signing I acknowledge that I am the person responsible
for the monitoring and administration of this contract, include
ensuring all performance and reporting requirements.
Jannette S. Goodall
City Secretary
❑There are NO City Funds associated with this Contract
OThere are City Funds associated with this Contract
Revised: 10-12-2011 Page 3
FORTWORTH
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Cibolo Hills Parkway Multi -Family Wayfare
CITY PROJECT NUMBER: 103516
WATER
PIPE LAID SIZE TYPE OF PIPE LF
Open Trench 16" PVC 2,917 LF
Open Trench 16" DIP 81 LF
Open Trench 12" PVC 110 LF
Open Trench 8" PVC 84 LF
FIRE HYDRANTS: 1 VALVES (16" OR LARGER) 5
PIPE ABANDONED SIZE TYPE OF PIPE LF
DENSITIES: Taken -Pass
NEW SERVICES: 2" IRR 60LF
SEWER
PIPE LAID
SIZE
TYPE OF PIPE LF
Open Trench
12"
PVC 570LF
Open Trench
12"
DIP 285LF
PIPE ABANDONED
SIZE
TYPE OF PIPE LF
DENSITIES:
Taken -Pass
NEW SERVICES:
6"
PVC 20LF
TRANSPORTATION AND PUBLIC WORKS
The City of Fort Worth • 1000 Throckmorton Street • Fort Worth, TX 76012-6311
FORTWORTH.
M"
TRANSPORTATION AND PUBLIC WORKS
9/15/2023
IMS Construction
5690 Watermelon Road, Suite 400
Northport, AL 35473
RE: Acceptance Letter
Project Name: Cibolo Hills Wayfare Multi -Family
Project Type: Water/Sewer/Stormdrain/Paving/Street Lighting
City Project No.: 103516
To Whom It May Concern:
On June 20, 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 September 15, 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 September 15,
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 871-
392-2481.
Sincerely,
Debbie Willhelm , Project Manager
Cc: Adrian Aranda , Inspector
Donald Watson , Inspection Supervisor
Aaron Ybarra , Senior Inspector
Jeff Hicks , Program Manager
Thomas C. Bartowski , Consultant
Bandera Utility Contractors Inc, Contractor
Wayfare Cibolo Hills LCC , Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Signature: A
Lauren Pricur (Oct 20, 2023 15:09 CDT)
Email: Lauren.Prieur@fortworthtexas.gov
Rev. 8/20/19
AFFIDAVIT
STATE OF ALABAMA
COUNTY OF TUSCALOOSA
Before me, the undersigned authority, a notary public in the state and county aforesaid,
on this day personally appeared William Keith Jones, President of fMS Construction, LLC.,
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:
Wayfare Multifamily Cibolo Hills Parkway
BY: i
V�illiam Keit ones, President
Subscribed mud s►i'orn before nic on this date 19"' of Oetober, 2023.
4NoaryPublic
� J�_C� I
Tuscaloosa, Alabama qi8� 9 a C��r,
ev A R
,1����•aee roe' ��? i
� � w
SUS LIC' ` �a
Q'
CONSENT OF SURETY
TO FINAL PAYMENT
"Doczm*W G707
Bond No. 60086143
Ta OWNM.
(Narnerandaddresx)
City of Fort Worth, Texas
200 Texas Street
Fort Worth, Texas 76102
PROJBCT.-
(rikiwandadrhnxv
WAYFARE MULTIFAMILY (CIBOLO HILLS PARKWAY)
T RAFFiC 3iGNAL MOWFit d i iuk i u SERVE
BUSINESS 287 AND CIBOLO HILLS PARKWAY
OWNER
ARMTEC!'
CONTRACTOR
SURM7Y
OTHER
ARCHI'F rs PROJECT NO.:
CONTMCTPOIt- CFA Number21-0104
CONMCT ATM: December 6, 2021
In accordance with the provisions of the Contract between die Owner and the Contt4ow as inditatett atxwe, the
prugr r menu a�rd ada�sr oJ'.sir>Cr}l
CAPITOL INDEMNITY CORPORATION
P.O. BOX 5900
Madison, WI 53705
on bond of
flawn namaarrdA*hu;,(fCmvraavr)
IMS Construction
5690 Watermelon Rd. Suite 400
Northport, AL 35473
, CQNTRAmx
hereby approves ofthe final payment to the Contractor, and agrees that tidal payment to the Ccuttractor 9hatt not relieve the Surety of
any of it3 obligations t0
C)�7svr1 tutmeand addax q j'[)rrrrer)
City of Fort Worth, Texas
200 Texas Street
Fort Worth, Texas 76102
as Set fbnb in said Surety's bond.
IN W TNMS VPMREOF, the Surety has hereunto set its hand on this date: October 20, 2023
(InawftjugYdiq?dwwontbfallourrfbt dewvnericarareandjva :t
Attest;
(sew),
Captial Indemnity Corporation
By:
(Sljqurertm�r�ttitbnrfzed �eynemntatier)
Debra Johnson, Attorney -in -Fact
(Prm1ad immandfilkI
Surety Phone No. 813-498-6275
0"7-1994
Lock Fields
CAPITOL INDEMNITY CORPORATION 60086143
POWER OF ATTORNEY Bond Number
KNOW ALL MEN BY THESE PRESENTS, That the CAPITOL INDEMNITY CORPORATION, a corporation of the State of Wisconsin, having its
principal offices in the City of Middleton, Wisconsin, does make, constitute and appoint
---ANDERSON L. GLENN; DEBRA JOHNSON; DOUGLAS L. RIEDER; JAMES C. CONGELIO; JAMES NASH CONGELIO; MARGARET S. MEYERS---
------- ---W WESLEY HAMILTON; MICHAEL J. BROWN; TAMEKA B. BLACK; TINA
its true and lawful Attorney(s)-in-fact, to make, execute, seal and deliver for and on its behalf, as surety, and as its act and deed, any and all bonds, undertakings
and contracts of suretyship, provided that no bond or undertaking or contract of suretyship executed under this authority shall exceed in amount the sum of
ALL WRITTEN INSTRUMENTS IN AN AMOUNT NOT TO E XCEED:$20,000,000.00---- ------------- ------------
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 CAPITOL INDEMNITY CORPORATION at a meeting duly called and held on the 15th day of May, 2002.
"RESOLVED, that the President, Executive Vice President, Vice President, Secretary or Treasurer, acting individually or otherwise, be and they hereby are
granted the power and authorization to appoint by a Power of Attorney for the purposes only of executing and attesting bonds and undertakings, and other
writings obligatory in the nature thereof, one or more resident vice-presidents, assistant secretaries and attomey(s)-in-fact, each appointee to have the powers and
duties usual to such offices to the business of this company; the signature of such officers and seal of the Company may be affixed to any such power of attorney
or to any certificate relating thereto by facsimile, and any such power of attorney or certificate bearing such facsimile signatures or facsimile seal shall be valid
and binding upon the Company, and any such power so executed and certified by facsimile signatures and facsimile seal shall be valid and binding upon the
Company in the future with respect to any bond or undertaking or other writing obligatory in the nature thereof to which it is attached. Any such appointment
may be revoked, for cause, or without cause, by any of said officers, at any time."
In connection with obligations in favor of the Florida Department of Transportation only, it is agreed that the power and authority 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 Attorney -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 CAPITOL INDEMNITY CORPORATION has caused these presents to be signed by its officer undersigned and
its corporate seal to be hereto affixed duly attested, this 1 st day of September, 2022.
Attest: J /
Ryan J. Byrnes
Senior Vice President,
Chief Financial Officer and Treasurer
Todd Burrick
Chief Underwriting Officer
CAPITOL INDEMNITY CORPORATION
Adam L. Sills
Chief Executive Officer and President
STATE OF WISCONSIN
COUNTY OF DANE SS.
On the 1st day of September, 2022 before me personally came Adam L. Sills, to me known, who being by me duly sworn, did depose and say: that he
resides in the County of New York, State of New York; that he is Chief Executive Officer and President of CAPITOL INDEMNITY
CORPORATION, the corporation described in and which executed the above instrument; that he knows the seal of the said corporation; that the seal affixed
to said instrument is such corporate seal; that it was so affixed by order of the Board of Directors of said corporation and that he signed his name thereto by
like order. \`\`\„allxrllllnrrnr„
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•ctN / David J. Regele
- Notary Public, Dane Co., WI
STATE OF WISCONSIN '%o„•••••."' \` ` M Commission is Permanent
COUNTY OF DANE SS..
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I, the undersigned, duly elected to the office stated below, now the incumbent in CAPITOL INDEMNITY CORPORATION, a Wisconsin Corporation,
authorized to make this certificate, DO HEREBY CERTIFY that the foregoing attached Power of Attorney remains in full force and has not been
revoked; and furthermore, that the Resolution of the Board of Directors, set forth in the Power of Attorney is now in force.
Signed and sealed at the City of Middleton, State of Wisconsin this 20th day of October 20 2023
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i% ::SEAL
Suzanne M. Broadbent
_
Assistant Secretary
THIS DOCUMENT HAS BEEN GENERATED FOR A SPECIFIC BOND. IF YOU HAVE ANY QUESTIONS CONCERNING THE
AUTHENTICITY OF THIS DOCUMENT CALL 800-475-4450. CIC-ePOA-M (Rev. 09-2022)