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Contract 59715-FP1
FORT WORTH, TRANSPORTATION AND PUBLIC WORKS NOTICE OF PROJECT COMPLETION -FP1 City Secretary No. 59715 Date Received: 8/20/2024 City Project N!?: 104771 Regarding contract 59715 2023 Concrete Restoration Contract 4 for as required by the TRANSPORTATION AND PUBLIC WORKS DEPARTMENT as approved by City Council on 6/26/2023 through M&C 23-0466 the director of the TRANSPORTATION AND PUBLIC WORKS DEPARTMENT upon the recommendation of the Assistant Director of the Transportation & Public Works Department has accepted the project as complete. Original Contract Amount: Amount of Approved Change Orders: Revised Contract Amount: Total Cost Work Completed: Less Deductions: Liquidated Damages: Pavement Deficiencies: Total Deduction Amount: Total Cost Work Completed: Less Previous Payments: Final Payment Due Pat�ici� L. WA Apt Patricia L. Wadsack (Aug 19, 202408:27 CDT) Recommended for Acceptance Asst. Director, TPW - Capital Delivery $ 2,280,180.00 Days 240 $ 78,450.00 Ns 3 Days Added by CO 50 $ 2,358,630.00 Total Days 290 $ 2,238,213.26 Days Charged 290 Days @ $ / Day $ (20,670.61) $ 2,217,542.65 $ 2,126,302.60 $ 91,240.05 Aug 19, 2024 Date A. Lau renPr (Aug ,202408:27 COT) Aug 19, 2024 Accepted Date Director, TRANSPORTATION AND PUBLIC WORKS DEPARTMENT Aug 20, 2024 Asst. City Manager Date Comments: OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX C-620 Signature Page Contractor's Application for Payment Invoice No. 12-FINAL To (Owner), City of Fort Worth Invoicing Period (From - To): Invoice Date: 7/1/24-7/31/24 8/2/2024 P. O FW02�1U�SS From (Contractor): Remit to ( If Not Automatic Deposit): - Number: Makou, Inc. Contractor'sCFW Vendor No.: Project: 104771 7000000265 City secretary contract 59715 Contract 2023 Concrete Resto Contract 4 Number: Nam: Application For Payment Change Order Summary Approved Change Orders 1. ORIGINAL CONTRACT PRICE.............................................................. $ $2,280,180.00 Number Additions Deletions 2. Net change by Change Orders.................................................................... $ $78,450.00 1 $33,050.00 3. Current Contract Price (Line 1 t 2)........................................................... $ $2,358,630.00 2 $25,400.00 4. TOTAL COMPLETED AND STORED TO DATE 3 $20,000.00 (Progress Estimate, Construction Allowance and Change Orders)....... $ $2,238,213.26 4 5. RETAINAGE: 5 a. X Work Completed.........., $ 6 Less Deductions X ($20,670.61) Not Used $ 7 c. Total Deductions (Line 5a + Line 5b)................................ $ $20,670.61 8 6. AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5c)................................ $ $2,217,542.65 TOTALS $78,450.00 7. LESS PREVIOUS PAYMENTS (Line 6 from prior Application).......... $ $2,126,302.60 NET CHANGE BY $78,450.00 8. AMOUNT DUE THIS APPLICATION..................................................... $ $91,240.05 CHANGE ORDERS 9. BALANCE TO FINISH, PLUS RETAINAGE (Column G on Progress Estimate+ CA + Cos + Line 5 above) ................ $ $141,087.35 Contractor's Certification 10. CONTRACT TIME: The Contractor certifies with the submittal of this document and associated Payment Request a. Days Awarded 240 Submittal on the City of Fort Worth Buzzsaw system that to the best of their knowledge: (1) all b. Days Added by CO 50 previous progress payments received from Owner on account of Work done under the Contract have been applied on account to discharge Contractor's legitimate obligations incurred in C. Total Days 290 connection with Work covered by prior Applications for Payment; (2) title of all Work, materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to Owner at time of payment free and clear of all Liens, security interests and d, Days Charged 290 encumbrances (except such as are covered by a Bond acceptable to Owner indemnifying Owner e. Days Remaining against any such Liens, security interest or encumbrances); and (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. Liquidated Damages $650.00 x day nWs� � Affidavit of Bills Paid magsood khan (Aug 15, 229 CDT) Consent of Surety This document has been modified from its original form as an EJCDC document and the user did not highlight the modifications. You are encouraged to read the document carefully and consult Legal Counsel prior to its execution. C-620 Unit Price Progress Estimate Progress Estimate CuySeuetery 59715 Contractor's Application Cormsct Num: Fnr(-sct) 2023 Concrete Resto Contract 4 AppticatinnNumber 12-FINAL AWIn,ation Period. 7/1/24-7/31/24 Application Date. 8/2/2024 Bid Item No. 1 A Item Description 0135 0201 Remobilimbon SpmiPcsbro Sedton No. 01 70 00 Unit of Measure EA Bid Qpantiry 1.000000 D Unn Pnce $50( OU B Btd Value $500 00 C Estimated Quntity Insmlled Valae Previously lnemlled Velae Value Thee Penod E Matenals Presently Stored(not m C) F Total Completed and Storedto Date (F) (D+E) B G Balance to Finish (B-F) $500.00 2 3471.0002 Portable Message Sign 347113 WK 24.000000 $70000 $16.80000 $16,800.00 3 9999 0000 Remove and Replace 6" Conuete Driveway 02 41 13/ 32 13 20 SF 220.000000 $14.00 $3,080.00 $1,004,904.60 $1,004,904.60 $3,080.00 4 99990000 Remove Concrete and Replace with 7" Concrete Pavement HES 0241151321313 BY 8787.000000 $10500 $922,63500 957052000000 $1,004,90460 10895/6 $82,269.60 5 9999.0000 Remove Concrete and Replace with 9" Concrete Pavement HES 02 41 15/32 13 13 BY 7345.000000 $111 00 $815.295 00 _ 7403 18000000 $821,752.98 $821,752.98 $821,752 98 100 8% -$6,457.98 $10,600.00 6 31230101 Unclassified Excavation 312316 CY 200.000000 $53.00 $10,600.00 7 3211 0122 Flex Be., Tvpe A. GR-2 3211 23 CY 2459.000000 $85 00 $209,015 00 2889 15000000 $245,577.75 $245.577.75 $245,577 75 117 5% $36,562.75 8 3213.0208 Concrete HES (extra depth) 321313 CY SY 150.000000 1000.000000 $210.00 $12.00 $31,500.00 $12,000.00 915.88000000 $10,990.56 $10,990.56 $31,500.00 9 32920100 Block Sod Placement 329213 $10,990.56 91.6% $1,009.44 10 3291 0100 Topsoil 3291 19 CY 100.000000 $54 25 $5,425 00 $5,425.00 11 3213.0700 Joint Sealant 321373 LF 2000.000000 $5.00 $10,000.00 $10,000.00 12 33050108 Miscellaneous Adjustment(Utilities) 330514 LS 1.000000 $5,000.00 $5,000.00 0,85286000 $4,264.30 $4,264.30 $4,264.30 85.3% $735.70 13 99990000 Geognd Tensar (TRIAX 140-475) or Approved eoual 99 99 00 SY 11066.000000 $5 00 $55,330 00 12975 16000000 $64,875.80 $64,875.80 $64,875 80 117 3% -$9,645.80 14 3217.2001 Raised Marker TY W 32 17 23 EA 400.000000 $6.00 $2,400.00 415 00000000 $2,490.00 $2,490.00 $2,49000 103.8% $90.00 15 3217 2002 Raised Marker TY Y 32 17 23 EA EA EA 100.000000 100.000000 100.000000 $6.00 $6 00 $6.00 $600.00 $600 00 $600.00 96 000000001 $576.00 $576.00 $600.00 16 32172101 REFL Raised Marker TY I -A 32 17 23 $576 00 96 0% $24.00 17 3217.2102 REFL Raised Marker TY I-C 321723 $600.00 18 3217 2103 REFL Raised Marker TY 11-A-A 32 17 23 EA 100.000000 $6.00 $600.00 $600.00 19 3217.2104 REFL Raised Marker TY 11-C-R 32 17 23 EA 100.000000 $6 00 $600 00 LF 600.000000 $10.00 $6,000.00 $600.00 $6,000.00 20 3441.1301 Loop Detector Cable Sawcut 344110 21 3441 1302 14 AWG Loop Detect Cable 344110 LF 600.000000 $12.00 $7,20000 $7,200.00 22 3217.0001 4" Solid Thermoplastic(HAS) Lane Line 321723 LF 400.000000 $400 $1.60000 80392000000 $3,215.68 $256.02 $3,215.68 $256.02 $3.21568 2010% -$1,615.68 23 3217 0201 6" Solid Thermoplastic (HAS) Lane Line 32 17 23 LF 1000.000000 $6.00 $6,000.00 42.67000000 $256.02 4.3% $5,743.98 24 3217 0301 8" SLD Pvmt Marking HAE 32 17 23 LF 400.00000O $8.00 $3,200 00 $3,200.00 25 3217.0401 18" SLID Pvmt Marking HAE 32 17 23 LF 400.000000 $10 00 $4.000 00 $4,000.00 26 3217 0601 24" SLD Pvmt Marking HAE 32 17 23 LF 800.000000 $12.00 $9,620.00 204.33000000 $2,451.96 $2,451.96 $2,451.96 25.5% $7,148.04 27 3213 0501 Remove and Replace Barrier Free Ramp Type P-1 02 41 13/ 32 13 20 EA 2.000000 $3,300.00 $6,600 00 1 00000000 $3,300.00 $3,300.00 $3,300 00 50 0% $3,300.00 28 3213.0501 Remove and Replace Bamer Free Ramp, Type R-1 02 41 13/ 32 13 20 EA 2.000000 $4.300 00 $8.600 00 $8,600.00 29 3213 0601 Remove and Replace Bamer Free Ramp, Type M-1/M-2 02 41 13132 13 20 EA 1.000000 $3,300.00 $3,300.00 $3,300.00 30 9999 0000 Remove and Replace 4" Sidewalk 02 41 13/ 32 13 20 SF 250.000000 $11 00 $2,750 00 39 25000000 $431.75 $431.75 $431 75 15 7% $2,318.25 31 3305.0106 Manhole Atllustment, Malor 330514 EA 2.000000 $2.50000 $5.00000 1.00g00000 $6,500.00 $6,500.00 $5,000.00 32 3305010510-Hunted Top Replacement 330514 EA 2.000000 $6,500.00 $13,000.00 $6,500.00 50.0% $6,500.00 33 3217 5001 Curb Address Painting 32 17 25 EA 10.000000 $75 00 $750 00 $750.00 34 9999.0096 Paving Construction Allowance EA 1.000000 $100,000.00 $100,000.00 $100,000.00 This tlocument has been modified from its original form as an EJCDC document and the user did not highlight the modifications. You are encouraged to read the document carefully and consult Legal Counsel prior to its execution C-620 Unit Price Progress Estimate Progress Estimate OtySe«euy 59715 Contractor's Application Con —Nun: For (eO -) 2023 Concrete Resto Contract 4 ApphaaOon Number 12-FINAL APPltcatioo Period. 7/1/24-7/31/24 APpltcahoo Date. 8/2/2024 A B C Item Fshmated Quntity Bid Item No. Descdphon Speciftcahon Sedlon No. Unit of Bid Quanhry Unn Pnce Bud Value Insmiisd Measure D E Matenals Presently Value P Value reviously Installed Value This Penod Stored(notm C) F G Total romplded Balance to Fimsh and Stored to Dale (F) IB-F) (D+E) B Totals $2,280,180.00 I2,111587.40 I2,1T1,58T.40 I2,111,01A0 65.2% $10115112.410 This tlocument has been modified from its original form as an EJCDC document and the user did not highlight the modifications. You are encouraged to read the document carefully and consult Legal Counsel prior to its execubon C-620 Change Order Progress Estimate Change Order Number 1 1 Contractor's Application ADDITIONS For (eontract): 104771 2023 Concrete Resto Contract 4 City Secretary 59715 Application Number: 12-FINAL Caramel Num: Application Period 7/1/24-7/31/24 Application Date' 8/2/2024 A B C D E F Item Addihw Balance to Finish Total Completed Change Order Lem Specification Uvrt of CO Quantity to Add Ural Price Change Order Estimated Qowtity Previously Value Value Valued Matmals Presently and Stored to Date (1) In - F) No Dwcrphon Section No Measure Value Installed Value Perod Stored (not m C) DIE) B 12 33050108 Miscellon—Adjusnnwt(Uhhoes) TPW LS 1.00000000 $18,00000 $18,00000 099741212 $17,953.42 $17,95342 $000 $17,95342 99.7% $4658 35-new a? i 7 nanl uMAC. T,ancirinn TPw TN zn nn... c77n nn Ffi fine nn a snnnnnnn ¢9on nn ¢99n nn S99n nn 15 .1 ss ail n nn 36-new 3216,03017" Con, Valley Goner REM/REP _ TPW SY 37-new 3213.05111 Burner Free Ramp, Type C-3 REM/REP TPW EA `Add 10 Days 50,00000000 $105.00 $5,250.00 39.83000000 $4,182.15 $4,182.15 $4,182.15 79.7% $1,067.85 t.00000000 $3,200.00 $3,200.00 1.00000000 $3,200.00 $3,200.00 $3,200.00 t00.0% Totals S33 050.00 $26 325.57 W6 325.57 S0.00 $26 325.57 79.7% S6 724.43 This document has been modified from its ongmal form as an E3CDC document and the user did not highlight the ous ificatious You are encouraged 10 read the document carefully and consult Legal Counsel prior to As execution C-620 Change Order Progress Estimate Change Order Number DELETIONS For (,mmaet): 104771 2023 Concrete Resto Contract 4 Appheano,, Fermat: 7/1/24-7/31/24 A Contractor's Application Applicator,, Number 12-FINAL Application Date: 8/2/2024 Item Change Order Item $pecificatwn Uvrt of No Description Sectloa No Measure CO Quantity to Delete Deter on Una Price Change Order Not Used Not Used Not Used Not Used Not Used No[ Used Value Not Used Not Uvcd Toran This docramor has bee, modified from its ongmal form as an EJCDC document and the user did not highlight the modifications You are encouaged to read the document carefully and consult Legal Counsel prior re, Its execution C-620 Change Order Progress Estimate Change Order Number 1 2 ADDITIONS For (contract): 104771 2023 Concrete Resto Contract 4 Application Pmod: A I[em Change Order Item Description No 12 3305 0108 Miscellaneous Adjustment (Utrlmea) 38-New 32171002 Lane Legend Arrow 39-New 9999 Landscape repair on FAA with Fleetwood -Add 20 Days Totals Contractor's Application City secretaryy 59715 Applreanon Number. 12-FINAL m: Contract Nu 7/1/24-7/31/24 ApplmattonDon, 8/2/2024 B C D E F Total Completed % Specification Unit of CO Qnannty 1. Add Uni[ Pvce Addnron Change Order Value Esnmated Qoariny Installed Value P,,. m ly Installed Velae Value This Penod Materials Presently Stored (not in C) and Stored to Date (F) Secfion No Measure (D+E) B LS 1.00000000 $18,00000 $M000.00 87791443 $15,802.46 $15,80246 $0.00 1 $15,802.46 878% FA 100000000 $40000 $40000 S400.00 100.0% LS 1.00000000 $7,000.00 $7,000.00 $4,097.83 58.5% $25,400.00 0.. 100000000 $400.00 $400.00 0.58540400 $4,097.83 $4,097.83 $0.00 $20,300.29 $20,300.29 $0.00 This dowment has been modified from ns origmal form as an EICDC document and the user did not highlight the modifications Yon are encouraged to read the document carefully and consult Legal Coonsel poor to ns -Eton. $20,300.29 79 9% Balance to Finish (B - F) $2,197.54 $2,902.17 C-620 Change Order Progress Estimate Change Order Number 1 2 DELETIONS For (contract): 104771 2023 Concrete Resto Contract 4 Application Number. APphcahov P—od: 7/1/24-7/31/24 Applrcahon Date A B C D E It— CO Quantity to Deletion Change Change Order hem No Descripttov Specification Unit of Delete Unit Price Order Value Not Used Section No Measure Not Used Not Used Not Used Not Used Totals This document has been modified from its odgmal form as an E1CDC document and the user did not highlight the modifications You are encouraged m read the document careflly and consult Legal C-1 poor to its execuaon. Contractor's Application 12-FINAL 8/2/2024 F Not Used Not Used Not Used C-620 Change Order Progress Estimate Change Order Number 1 3 ADDITIONS For (oovt h: 104771 2023 Concrete Resto Contract 4 APphcahov Pmod: A I[em Change Order Item Descov No. riptr 12 3305 0108 Miscellaneous Adjustment (Uhlrhes) `Add 20 Days Totals Contractor's Application City Seeretary 59715 Application Number 12-FI Contract Nam 7/1/24-7/31/24 Application Date: 8/2/7 B C D E F Additio¢ Total Completed % Specificatio¢ Unit of CO Quantity to Add Unit Price Change Order Estimated Quantity Value Previously Value This Matenals Presently avd Sfred to Date (F) Sactio¢ No. Measure Value Installed Installed Value Period Stored (.or in C) (D I E) B LS 100000000 $20,000 00 $20,000 00 1.00000000 $20,000 00 $20,000 00 1 $20,000 00 100 0% $20,000.00 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I _ I I I $20,000.00 $20,000.00 This document has been modified from ns origmal form as an E1CDC document and the user did ¢ot htghlrght the modifications You are encouraged m read the document camflly and consult Legal Counsel pnor to ns execution. C-620 Change Order Progress Estimate Change Order Number 1 3 DELETIONS For (contract): 104771 2023 Concrete Resto Contract 4 Application Number. Apph-ton P—od: 7/1/24-7/31/24 Application Date: A B C D E Ilan CO ti to �� N Deletion Change Order hem No Description Specification Unit of Section No Measure Delete Unit Price Change Order Not Used Value Not Used Not Used Not Used Not Used Totals This document has been modified from as odgmal form as an EJCDC document and the user did not htghlrght the modifications You are encouraged m read the document careflly and consult Legal Couvsel poor to ns execution. Contractor's Application 12-FINAL 8/2/2024 F Not Used Not Used Not Used City Secretary Contract Num: I 59715 Application Period: Funding Identification (FID) On, Mal Contract 130100-0200431-5740010-10l-E03380-9999 10 10 10 10 10 10 10 10 10 10 Change Order 1 130100-0200431-5740010-104771-E03380-9999 10 10 10 10 10 10 10 10 10 10 Change Order 2 130100-0200431-5740010-104771-E03380-9999 10 10 10 10 10 10 10 10 10 10 City of Fort Worth Summary of Charges 2023 Concrete Resto Contract 4 I P. D: FW020-10055 Project Number: 104771 7/1/24-7/31/24 I Application I 12-FINAL Application Date: 8/2/2024 Number: Total Completed $2,171,587.40 $26,325.57 $20,300.29 Amt Remaining $108,592.60 $6,724.43 $5,099.71 I Gross I I Retainage I I ($0.00) ($0.00) Net ($0.00) ($0.00) City Secretary Contract Num: I 59715 Application Period: City of Fort Worth Summary of Charges 2023 Concrete Resto Contract 4 I P. D: FW020-10055 Project Number: 104771 7/1/24-7/31/24 I Application I 12-FINAL Application Date: 8/2/2024 Number: Funding Identification (FID) Total Completed Amt Remaining Gross Retainage Change Order 3 130100-0200431-5740010-104771-E03380-9999 1 $20,000.00 $0.00 $0.00 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 I I $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 I I $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.001 1 $0.0( 130100-0200431-5740010-104771-E03380-9999 10 to 10 to 10 10 10 10 to 10 to 10 10 10 10 to 10 10 10 Net City Secretary Contract Num: I 59715 Application Period: City of Fort Worth Summary of Charges 2023 Concrete Resto Contract 4 I P. D: FW020-10055 Project Number: 104771 7/1/24-7/31/24 I Application I 12-FINAL Application Date: 8/2/2024 Number: Funding Identification (FID) Total Completed Amt Remaining Gross Retainage Change Order 6 130100-0200431-5740010-104771-E03380-9999 1 $0.00 $0.00 $0.00 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 I I $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 I I $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 1 1 $0.00 1 1 $0.00 1 1 $0.00 1 1 $0.0( 10 I I I I $0.00 1 1 $0.00 1 1 $0.0( 10 I I I I $0.001 1 $0.001 1 $0.0( 10 I I I I $0.001 1 $0.001 1 $0.0( I Change Order 7 130100-0200431-5740010-104771-E03380-9999 10 to 10 to 10 10 10 10 to 10 to 10 10 10 10 to 10 10 10 Net City of Fort Worth Summary of Charges City Secretary Contract Num: I 59715 I Application Period: Funding Identification (FID) 2023 Concrete Resto Contract 4 I P. D: I 7/1/24-7/31/24 I Application I Number: Total Completed Amt Remaining FW020-10055 12-FINAL Gross I Project Number: Application Date: 104771 8/2/2024 I Retainage I F-Net Totals 130100-0200431-5740010-104771-E03380-9999 $2,238,213.26 $120,416.74 ($0.00) $0.00 ($0.00) 10 $0.00 1 1 $0.00 1 1 $0.00 10 JU $0.00 1 1 $0.00 1 1 $0.00 10 ).00 1 1 $0.00 1 1 $0.00 1 1 $0.00 10 ).00 I 1 $0.00 1 1 $0.00 1 1 $0.00 1 10 ).00 I 1 $0.00 1 1 $0.00 1 1 $0.00 10 D.00 I 1 $0.00 1 1 $0.00 1 1 $0.00 10 D.00 I 1 $0.00 1 1 $0.00 10 D.00 I 1 $0.00 1 1 $0.00 1 10 $0 00 1 1 1 Z�u., $0.00 1 1 $0.00 10 11 1 1 I �n nr Grand Total $2,238,213.26 1 1 $120,416.74 1 ($0.00)1 1 ($91,240.05)1 1 $91,240.05 FORT WORTH - Routing and Transmittal Slip Transportation & Public Works Department DOCUMENT TITLE: 2023 CONCRETE RESTORATION CONTRACT 4 M&C: 23-0466 CPN: 104771 CSO: 59715 DOC#: COI Date: 09/01/2023 _ To: Name Department Initials Date Out 1 Anitra Robbins (BSP) TPW AR AR Oct 11, 2023 2 Magsood Khan/Makou, Inc. Vendor maK Oct 11, 2023 3 Habte Taezaz (Inspector) TPW iae Oct 15, 2023 4 Marwan Hafez (PM) TPW Oct 11, 2023 5 Omar Elbagalati (PGM) TPW Oct 15, 2023 6 Mary Hanna (SCPO) TPW N/' Oct 16, 2023 7 Patricia Wadsack (AD) TPW ,L TLW Oct 16, 2023 8 Lauren Prieur (Director) TPW _� Oct 16, 2023 9 Doug Black (ACA) Legal Jwb Oct 17, 2023 10 William Johnson (ACM) CMO N Oct 18, 2023 11 Jannette Goodall (CS) CSO s�a Oct 18, 2023 10 TPW Contracts TPW CC: Program Manager, Sr. CPO, TPW BSPAP Recon Team, TPW Records Room, TPW Contracts ALSO List: -Bus Sppt: Prg Mgr: Sr CPO: DOCUMENTS FOR CITY MANAGER'S SIGNATURE: All documents received from any and all City Departments requesting City Manager's signature for approval MUST BE ROUTED TO THE APPROPRIATE ACM for approval first. Once the ACM has signed the routing slip, David will review and take the next steps. NEEDS TO BE NOTARIZED: DYES ®No RUSH: ❑YES ®No SAME DAY: DYES ❑No NEXT DAY: DYES ®No ROUTING TO CSO: ®YES ❑No Action Required: ❑ Attach Signature, Initial and Notary Tabs ❑ As Requested ❑ For Your Information ® Signature/Routing and or Recording ❑ Comment ❑ File Return To: Please notify TPWContracts(a fortworthtexas.2ov for pickup when complete. Call ext. 7233 or ext. 8363 with questions. Thank you! CSC No. 59715-COI FORT WORTH , City of Fort Worth ` 11' Change Order Request Project Name 2023 Concrete Restoration Contract 4 I City Sec # I 59715 Client Project #(s)� 104771 Project Description Concrete pavement replacement on various locations Contractor Makou Inc. Change Order#1 1 1 Datel 9/27/2023 City Project Mgr.1 Marwan Hafez City Inspectorl Habte Taezaz Dept. Original Contract Amount Extras to Date Credits to Date Pending Change Orders (in M&C Process) Contract Cost to Date Amount of Proposed Change Order Revised Contract Amount Original Funds Available for Change Orders Remaining Funds Available for this CO Additional Funding (if necessary) TPW $2,280,180.00 $2,280,180.00 $33,050.00 $2,313,230.00 $100,000.00 $100,000.00 Contract Time Totals (CD` $2,280,180.00 240 $2,280,180.00 240 $33,050.00 10 $2,313,230.00 250 $100,000.00 $100,000.00 CHANGE ORDERS to DATE (INCLUDING THIS ONE) AS % OF ORIGINAL CONTRACT 1.45% MAX ALLOWABLE CONTRACT AMOUNT (ORIGINAL CONTRACT COST+ 25%) $2,850,225.00 JUSTIFICATION (REASONS) FOR CHANGE ORDER This Change Order is to increase the scope of work and add more quantities in the Construction Contract 59715. The additional work description and locations are as follows: Use asphalt transition on Morton Street due to the adjacent asphalt pavement on the parking lot. Remove and replace 7" valley gutter on Morton St due to the poor conditions found. Remove and replace barrier free ramp, Type C-3 at 4801 Marine Creek Pkwy due to the poor conditions found. Add quantities for irrigation under current Item 12. The contractor already used almost 80% of this bid item which is paid by the plumber invoice plus 10% overhead. All plumber invoices are available on BIM 360 for reference. The prices for the new line items have been compared with prices from similar contracts and deemed to be reasonable. Staff recommends adding 10 days for the asphalt transition and the valley gutter construction which were outside the scope of work. The other activities shouldn't be considered for additional days. 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. The Project/Program Manager signing below acknowledges that he/she is the person responsible for the monitoring and administration of this contract, including ensuring all performance and reporting requirements. NNEWontractor's Company Name lContractor (Nam r Contract Si nature Makou, Inc. Magsood Khan ,,,,,,,.,o,,,,,a,, .,,. Oct 11, 2023 n Supervisor Date Proect and CoMCompliance Manager W Date Oct15,2023 Oct 11, 2023nsectio mManaer Date Senior Capital Project Officer Date Oct 15, 2023 Oct 16, 2023 Date Director, Contracting Department (Dept) Date Oct 16, 2023 Oct 16, 2023 ssistant City Attorne 9 pt Date Oct 17, 2023 Assistant City Mana er „o 8303 Boa p Date Oct 18, 2023 Council Action if re wire M&C Number I I M&C Date Approved ATTEST: q,,..,.. a .dam... Jannette Goodall, City Secretary FORTWORTH City of Fort Worth '!" Change Order Additions Project Name 2023 Concrete Restoration Contract 4 City Sec # 59715 Client Project # 104771 1 Contractorl Makou Inc. I PMI Marwan Hafez Inspectorl Habte Taezaz Change Order Submittal # Date 1 9/27/2023 ADDITIONS ITEM DESCRIPTION DEPT Unit Unit Cost Total 1 12 3305.0108 Miscellaneous Adjustment (Utilities) TPW % 0000000 LS $18,000.00 $18,000.001 35-new 3212.0401 HMAC Transition TPW 30.00000000 TN $220.00 $6,600.001 36-new 3216.0301 7" Conc Valley Gutter REM/REP TPW 50.00000000 SY $105.00 $5,250.001 37-new 3213.0510 Barrier Free Ramp, Type C-3 REM/REP TPW 1.00000000 EA $3,200.00 $3,200.001 TPW $33,050.001 1 1 1 Sub Total Additions $33,050.001 Change Order Additions Page 2 of 4 ItM FOx_� City of Fort Worth Change Order Deletions Project Name 1 2023 Concrete Restoration Contract 4 City Sec # 1 59715 Client Project # 1 104771 1 Contractorl Makou Inc. PMI Manvan Hafez I Inspectorl Habte Taezaz I Change Order Submittal # Date 1 9/27/2023 1 DELETIONS UtSUNIHI IUN DEFT Uty Unit Unit host total 1 I 1 1 1 1 I I 1 I I 1 1 I 1 I I 1 I 1 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 I I 1 TM $0.001 1 1 1 Sub Total Deletions $0.001 Change Order Deletions Page 3 of 4 M/SBE for this Change Order M/SBE Sub Type of Service T Amount for this CO Total $0.00 Previous Change Orders co # DATE I AMOUNT Total I $0.00 1 FORT WORTH Routing and Transmittal Slip Transportation & Public Works. Department DOCUMENT TITLE: 2023 CONCRETE RESTORATION CONTRACT 4 M&C: 23-0466 CPN: 104771 CSO: 59715 DOC#: CO2 Date: 03/22/2024 To: Name Department Initials Date Out 1 Wendi Hedlund (BSP) TPW „ Apr 1, 2024 2 Magsood Khan/Makou, Inc. Vendor ut Mar 30, 2024 3 Habte Taezaz (Inspector) TPW M H. Apr 3, 2024 4 Marwan Hafez (PM) TPW MH Mar 29, 2024 5 Zelalern Arega (PGM) TPW z ZA Apr 3, 2024 6 Mary Hanna (SCPO) TPW NW Apr 4, 2024 7 Patricia Wadsack (AD) TPW ��,'�/�/' Apr 9, 2024 g Lauren Prieur (Director) TPW atrz Apr 9, 2024 9 Doug Black (ACA) Legal Apr 11, 2024 10 Jesica McEachern (ACM) CMO oa Apr 11, 2024 11 Jannette Goodall (CS) CSO �� Apr 12, 2024 12 TPW Contracts TPW CC: Program Manager, Sr. CPO, TPW BSPAP Recon Team, TPW Records Room, TPW Contracts ALSO List: -Bus Sppt: Wendi Hedlund; Prg Mgr: Zelalem Are a; Sr CPO: Marry Hanna DOCUMENTS FOR CITY MANAGER'S SIGNATURE: All documents received from any and all City Departments requesting City Manager's signature for approval MUST BE ROUTED TO THE APPROPRIATE ACM for approval first. Once the ACM has signed the routing slip, David will review and take the next steps. NEEDS TO BE NOTARIZED: DYES ®No RUSH: DYES ®No SAME DAY: DYES ❑No NEXT DAY: DYES ®No ROUTING TO CSO: ®YES ❑No Action Required:_ ❑ Attach Signature, Initial and Notary Tabs ❑ As Requested ❑ For Your Information ® Signature/Routing and or Recording ❑ Comment ❑ File Return To: Please notify TPWContractsafortworthtexas.gov for pickup when complete. Call ext. 7233 or ext. 8363 with questions. Thank you! CSC No. 59715-CO2 Project Name 2023 Concrete Restoration Contract 4 Client Project #(s)l 104771 Project Description Contractor) Makou Inc. City Project Mgr.l Marwan Hafez Dept. Original Contract Amount Extras to Date Credits to Date Pending Change Orders (in M&C Process) Contract Cost to Date Amount of Proposed Change Order Revised Contract Amount Original Funds Available for Change Orders Remaining Funds Available for this CO Additional Funding (if necessary) TPW $2,280,180.00 $33,050.00 City of Fort Worth Change Order Request I City Sec # l 59715 Concrete pavement replacement on various locations Change Order#I 2 1 Date 3/22/2024 City Inspectorl Habte Taezaz $2,313,230.00 $25,400.00 $2,338,630.00 $100,000.00 $66,950.00 Contract Time Totals (CD) $2,280,180.00 240 $33,050.00 10 $2,313,230.00 250 25,400.00 20 $2, 38,630.00 270 $100,000.00 $66,950.00 CHANGE ORDERS to DATE (INCLUDING THIS ONE) AS % OF ORIGINAL CONTRACT 1 2.56% MAX ALLOWABLE CONTRACT AMOUNT (ORIGINAL CONTRACT COST+ 25%) 1 $2,850,225.00 JUSTIFICATION (REASONS) FOR CHANGE ORDER This Change Order #2 will provide for: 1. Installing a left -turn pavement markings arrow legend on FAA Blvd. 2. Additional quantities for irrigation utility adjustments on Championship Pkwy under the existing Item 12. Due to site condition and the locations of the existing irrigation system in the parkway and median behind the curb, It's necessary to increase the allowance under this bid item to repair the damaged system during construction. 3. Repair the existing landscape on FAA Blvd at Fleetwood Rd, including adding river rocks over an area of almost 200 square feet. The pricing for the new bid item, the left -turn arrow, has been compared against rates from comparable contracts and deemed reasonable. Staff recommends adding 20 days for the contractor to complete this work to install the left -turn arrow legend, irrigation utility adjustments, and landscape repairs. 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. The Project/Program Manager signing below acknowledges that he/she is the person responsible for the monitoring and administration of this contract, including ensuring all performance and reporting requirements. Contractor's Company Name Contractor (Name) Wr Contract Signature Makou, Inc. Maqsood Khan �`" Mar 30, 2024 Inspector/Inspection Supervisor Date Project and Contract Compliance Manager Date Apr 3, 2024 Mar 29, 2024 o ram Mana er Date Senior Capital Project Officer Date Itl�ir�hyY' Apr 3, 2024 Apr 4, 2024 erector (Dept) Date Director, Contracting Department (Dept) Date Pat ✓icia / WadsacK Apr 9, 2024 A — a. Apr 9, 2024 sistant Cit Attorney Date Assistant CityManager Apr 11, 2024 Apr 11, 2024 Council Action if required) M&C Number I M&C Date Approved ATTEST: A &— Jannette Goodall, City Secretary FORT WORTH City of Fort Worth 'W' Change Order Additions Project Name 1 2023 Concrete Restoration Contract 4 City Sec # 59715 Client Project # 1 104771 1 Contractorl Makou Inc. I PMI Marwan Hafez Inspectorl Habte Taezaz I Change Order Submittal # Date ( 3/22/2024 ADDITIONS ITEM DESCRIPTION DEPT Ot Unit Unit Cost Total 12 3305.0108 Miscellaneous Adjustment (Utilities) TPW 1 Y 000000(1 LS $18,000.00 $18,000.001 38-new 3217.1002 Lane Legend Arrow TPW 1.00000006 EA $400.Od $400.001 39-new 9999 Landscape repair on FAA with Fleetwood TPW 1.00000000 LS $7,000.Od $7,000.001 TPW $25,400.001 1 1 1 Sub Total Additions $25,400.001 Change Order Additions Page 2 of 4 1 I tM FORT WORTH City of Fort Worth V" Change Order Deletions Project Name 1 2023 Concrete Restoration Contract 4 1 City Sec # 1 59715 1 Client Project# 1 104771 1 Contractorl Makou Inc. I PMI Manvan Hafez I Inspectorl Habte Taezaz I Change Order Submittal # Date 1 3/22/2024 1 DELETIONS Utbl:KIF'I IUN MY Uty Unit Unit lost total I 1 I I I I I 1 1 1 1 I I I I I I I I I I I I I I I I I I I I 1 I I I I I I I I I 1 1 1 I I I I I I 1 1 1 1 1 1 I I I 1 1 1 1 1 1 1 1 1 I 1 TPW $0.001 I I Sub Total Deletions $0.001 Change Order Deletions Page 3 of 4 M/SBE for this Change Order M/SBE Sub Type of Service 7Amount for this CO $0.00 Total I $0.00 I Previous Change Orders Co # DATE I AMOUNT CO #1 9/27/2023 $0.00 Total I $0.00 1 104771-CNCO-2023 Concrete Restoration Contract 4 CO2 Interim Agreement Report 2024-03-30 Created: 2024-03-29 By: Andrea Munoz (Andrea. M unoz@fortworthtexas.gov) Status: Out for Signature Transaction ID: CBJCHBCAABAA8Klx2NDLZPOBPUS5RfflMygzOkSWNvOg Agreement History Agreement history is the list of the events that have impacted the status of the agreement prior to the final signature. A final audit report will be generated when the agreement is complete. "104771-CNCO-2023 Concrete Restoration Contract 4 CO2" His tory Document created by Andrea Munoz (Andrea.Munoz@fortworthtexas.gov) 2024-03-29 - 9:38:59 PM GMT- IP address: 204.10.90.100 Document emailed to Wendi Hedlund(wendi.hedlund@fortworthtexas.gov) for filling 2024-03-29 - 9:50:56 PM GMT Document emailed to makouinc@gmail.com for signature 2024-03-29 - 9:50:57 PM GMT Document emailed to Habte Taezaz (Habte.Taezaz@fortworthtexas.gov) for signature 2024-03-29 - 9:50:57 PM GMT Document emailed to Marwan Mohamed Saad Hafez(marwan.hafez@fortworthtexas.gov) for signature 2024-03-29 - 9:50:57 PM GMT Email viewed by makouinc@gmail.com 2024-03-29 - 9:51:09 PM GMT- IP address: 66.102.6.97 "6 Signer makouinc@gmail.com entered name at signing as MAQSOOD 2024-03-29 - 9:53:26 PM GMT- IP address: 172.58.139.77 - Document e-signed by MAQSOOD (makouinc@gmail.com) Signature Date: 2024-03-29 - 9:53:28 PM GMT - Time Source: server- IP address: 172.58.139.77 FORTW❑RTHg I P--dhy Adobe Acrobat Sign Email viewed by Marwan Mohamed Saad Hafez (marwan.hafez@fortworthtexas.gov) 2024-03-29 - 9:54:41 PM GMT- IP address: 204.10.90.100 Document e-signed by Marwan Mohamed Saad Hafez (marwan.hafez@fortworthtexas.gov) Signature Date: 2024-03-29 - 9:56:17 PM GMT - Time Source: server- IP address: 204.10.90.100 Email viewed by Habte Taezaz (Habte.Taezaz@fortworthtexas.gov) 2024-03-30 - 6:00:06 AM GMT- IP address: 104.28.97.28 FDRTW❑RTHg I P--dhy Adobe Acrobat Sign 104771-CNCO-2023 Concrete Restoration Contract 4 Final Audit Report 2024-04-12 Created: 2024-03-30 By: Andrea Munoz (Andrea. Mu noz@fortworthtexas.gov) Status: Signed Transaction ID: CBJCHBCAABAAv_7rhjuwFvrMDrsp29Vid6P1IBu3gy-r "104771-CNCO-2023 Concrete Restoration Contract 4" History Document created by Andrea Munoz (Andrea. Munoz@fortworthtexas.gov) 2024-03-30 - 11:48:56 PM GMT- IP address: 204.10.90.100 P+ Document emailed to Wendi Hedlund(wend i.hedlund@fortworthtexas.gov) for filling 2024-03-31 - 0:05:29 AM GMT P+ Document emailed to Habte Taezaz (Habte.Taezaz@fortworthtexas.gov) for signature 2024-03-31 - 0:05:29 AM GMT Email viewed by Wendi Hedlund(wendi.hedlund@fortworthtexas.gov) 2024-03-31 - 0:05:34 AM GMT- IP address: 40.94.28.254 Email viewed by Habte Taezaz (Habte.Taezaz@fortworthtexas.gov) 2024-04-01 - 2:17:32 AM GMT- IP address: 104.28.97.24 &0 Form filled by Wendi Hedlund(wendi.hedlund@fortworthtexas.gov) Form filling Date: 2024-04-01 - 12:58:46 PM GMT - Time Source: server- IP address: 204.10.90.100 40- Document e-signed by Habte Taezaz(Habte.Taezaz@fortworthtexas.gov) Signature Date: 2024-04-03 - 5:25:48 PM GMT - Time Source: server- IP address: 172.59.196.73 4 Document emailed to Zelalem Arega(Zelalem.Arega@fortworthtexas.gov) for signature 2024-04-03 - 5:25:50 PM GMT �i Email viewed by Zelalem Arega (Zelalem.Arega@fortworthtexas.gov) 2024-04-03 - 8:21:32 PM GMT- IP address: 204.10.91.100 6S0 Document e-signed by Zelalem Arega (Zelalem.Arega@fortworthtexas.gov) Signature Date: 2024-04-03 - 8:22:21 PM GMT - Time Source: server- IP address: 204.10.91.100 FoRTWORTHs I Pawem"Y Adobe Acrobat Sign Document emailed to Mary Hanna (Mary.Han na@fortworthtexas.gov) for signature 2024-04-03 - 8:22:23 PM GMT Document e-signed by Mary Hanna (Mary.Hanna@fortworthtexas.gov) Signature Date: 2024-04-04 - 4:09:33 PM GMT - Time Source: server- IP address: 204.10.90.100 Document emailed to Patricia Wadsack (patricia.wadsack@fortworthtexas.gov) for signature 2024-04-04 - 4:09:35 PM GMT Signer Patricia Wadsack (patricia.wadsack@fortworthtexas.gov) entered name at signing as Patricia L. Wadsack 2024-04-09 - 8:50:41 PM GMT- IP address: 204.10.90.100 &0 Document e-signed by Patricia L. Wadsack (patricia.wadsack@fortworthtexas.gov) Signature Date: 2024-04-09 - 8:50:43 PM GMT - Time Source: server- IP address: 204.10.90.100 P+ Document emailed to Lauren Prieur (Lauren.Prieur@fortworthtexas.gov) for signature 2024-04-09 - 8:50:45 PM GMT Email viewed by Lauren Prieur (Lauren.Prieur@fortworthtexas.gov) 2024-04-09 - 11:11:35 PM GMT- IP address: 166.205.54.3 &0 Document e-signed by Lauren Prieur (Lauren.Prieur@fortworthtexas.gov) Signature Date: 2024-04-09 - 11:12:42 PM GMT - Time Source: server- IP address: 166.205.54.3 C'-r Document emailed to Priscilla Ramirez (Priscilla.Ramirez@fortworthtexas.gov) for approval 2024-04-09 - 11:12:44 PM GMT f) Email viewed by Priscilla Ramirez (Priscilla.Ramirez@fortworthtexas.gov) 2024-04-10 - 1:01:43 PM GMT- IP address: 204.10.90.100 hie Document approved by Priscilla Ramirez (Priscilla.Ramirez@fortworthtexas.gov) Approval Date: 2024-04-10 - 1:01:57 PM GMT - Time Source: server- IP address: 204.10.90.100 C', Document emailed to Douglas Black (Douglas.Black@fortworthtexas.gov) for signature 2024-04-10 - 1:01:59 PM GMT 60Document e-signed by Douglas Black (Douglas.Black@fortworthtexas.gov) Signature Date: 2024-04-11 - 9:00:21 PM GMT - Time Source: server- IP address: 204.10.90.100 Cy Document emailed to Jesica McEachern aesica.mceachern@fortworthtexas.gov) for signature 2024-04-11 - 9:00:28 PM GMT 6© Document e-signed by Jesica McEachern Qesica.mceachern@fortworthtexas.gov) Signature Date: 2024-04-12 - 4:01:18 AM GMT - Time Source: server- IP address: 69.212.100.108 FoRTWORTHs I '"Y Adobe Acrobat Sign Document approval automatically delegated to Katherine Cenicola (Katherine.Cenicola@fortworthtexas.gov) by Ronald Gonzales (Ronald.Gonzales@fortworthtexas.gov) 2024-04-12 - 4:01:20 AM GMT Document emailed to Ronald Gonzales (Ronald.Gonzales@fortworthtexas.gov) for approval 2024-04-12 - 4:01:20 AM GMT Document emailed to Katherine Cenicola (Katherine.Cenicola@fortworthtexas.gov) for approval 2024-04-12 - 4:01:21 AM GMT Email viewed by Katherine Cenicola (Katherine.Cenicola@fortworthtexas.gov) 2024-04-12 - 12:52:29 PM GMT- IP address: 104.47.65.254 &0 Document approved by Katherine Cenicola (Katherine.Cenicola@fortworthtexas.gov) Approval Date: 2024-04-12 - 12:52:41 PM GMT - Time Source: server- IP address: 204.10.90.100 P+ Document emailed to Jannette Goodall Oannette.goodall@fortworthtexas.gov) for signature 2024-04-12 - 12:52:42 PM GMT ,) Email viewed by Jannette Goodall Qannette.goodall@fortworthtexas.gov) 2024-04-12 - 12:54:33 PM GMT- IP address: 204.10.90.100 &0 Document e-signed by Jannette Goodall Oannette.goodall@fortworthtexas.gov) Signature Date: 2024-04-12 - 12:54:45 PM GMT - Time Source: server- IP address: 204.10.90.100 rB Form filling automatically delegated to Elisa Winterrowd (Elisa.Winterrowd@fortworthtexas.gov) by Allison Tidwell (aIIison.tidwelI@fortworthtexas.gov) 2024-04-12 - 12:54:46 PM GMT C'y Document emailed to Allison Tidwell (allison.tidwell@fortworthtexas.gov) for filling 2024-04-12 - 12:54:47 PM GMT C'-. Document emailed to Elisa Winterrowd (Elisa.Winterrowd@fortworthtexas.gov) for filling 2024-04-12 - 12:54:47 PM GMT &. Form filled by Allison Tidwell (allison.tidwell@fortworthtexas.gov) Form filling Date: 2024-04-12 - 2:05:09 PM GMT - Time Source: server- IP address: 204.10.90.100 Q Agreement completed. 2024-04-12 - 2:05:09 PM GMT FDRTWORTHs I Paw m"Y Adobe Acrobat Sign FORT WORTH. Routing and Transmittal Slip Transportation & Public Works Department DOCUMENT TITLE: 2023 CONCRETE RESTORATION CONTRACT 4 M&C: 23-0466 CPN: 104771 CSO: 59715 DOC#: CO3 Date: 5/3/2024 To: Name Department Initials Date Out 1 Sophia Flores (BSP) TPW Ste- May 8, 2024 2 Magsood Khan/Makou, Inc. Vendor May 8, 2024 3 Habte Taezaz (Inspector) TPW rILk May 8, 2024 4 Marwan Hafez (PM) TPW Mff May 8, 2024 5 Zelalem Arega (PGM) TPW Zfk May 8, 2024 6 Mary Hanna (SCPO) TPW=' May 9, 2024 7 Patricia Wadsack (AD) TPW May 9, 2024 8 Lauren Prieur (Director) TPW May 9, 2024 9 Doug Black (ACA) Legal May 13, 2024 10 Jesica McEachern (ACM) CMO May 17, 2024 11 Jannette Goodall (CS) CSO 6 May 17, 2024 12 TPW Contracts TPW CC: Program Manager, Sr. CPO, TPW BSPAP Recon Team, TPW Records Room, TPW Contracts ALSO List: - Bus Sppt: Sophia Flores; Prg Mgr: Zelalem AreQa; Sr CPO: Mary Hanna DOCUMENTS FOR CITY MANAGER'S SIGNATURE: All documents received from any and all City Departments requesting City Manager's signature for approval MUST BE ROUTED TO THE APPROPRIATE ACM for approval first. Once the ACM has signed the routing slip, David will review and take the next steps. NEEDS TO BE NOTARIZED: DYES ®No RUSH: DYES ❑No SAME DAY: DYES ❑No NEXT DAY: DYES ®No ROUTING TO CSO: ®YES ❑No Action Required: ❑ Attach Signature, Initial and Notary Tabs ❑ As Requested ❑ For Your Information ® Signature/Routing and or Recording ❑ Comment ❑ File Return To: Please notify TPWContractsna,fortworthtexas.gov for pickup when complete. Call ext. 7233 or ext. 8363 with questions. Thank you! CSC No. 59715-CO3 FORT WORTH,:, "11� City of Fort Worth Change Order Request Project Name 2023 Concrete Restoration Contract 4 I City Sec # l 59715 Client Project #(s)l 104771 Project Description) Concrete pavement replacement on various locations Contractorl Makou Inc. Change Order#1 3 1 Datel 5/3/2024 City Project Mgr.l Manvan Hafez City Inspectorl Habte Taezaz Dept. TPW Contract Time Totals (CD) Original Contract Amount $2,280,180.00 $2,280,180.00 240 Extras to Date $58,450.00 $58,450.00 30 Credits to Date Pending Change Orders (in M&C Process) Contract Cost to Date $2,338,630.00 $2,338,630.00 270 Amount of Proposed Change Order $20,000.00 $20,000.00 20 Revised Contract Amount $2,358,630.00 $2,358,630.00 290 Original Funds Available for Change Orders $100,000.00 $100,000.00 Remaining Funds Available for this CO $41,550.00 $41,550.00 Additional Funding (if necessary) CHANGE ORDERS to DATE (INCLUDING THIS ONE) AS % OF ORIGINAL CONTRACT 3.47. MAX ALLOWABLE CONTRACT AMOUNT (ORIGINAL CONTRACT COST+ 15%) $2,850,225.00 JUSTIFICATION (REASONS) FOR CHANGE ORDER This Change Order #3 will provide for: 1. Additional quantities for irrigation utility adjustments on Championship Pkwy under the existing Item 12. Due to the site conditions of damaged concrete panels and drainage issues, more panels were considered for replacement on Championship Pkwy. The additional concrete panel replacement required fixing the existing irrigation system in the parkway and median behind the curb. It's necessary to increase the allowance under this bid item to repair the damaged system during construction. 2. Adding 20 days for the contractor to complete the additional work. 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. The Project/Program Manager signing below acknowledges that he/she is the person responsible for the monitoring and administration of this contract, including ensuring all performance and reporting requirements. Contractor's Company Name Contractor Name Contract Si natur Date Makou, Inc. Maqsood Khan May 8, 2024 ector/Inspection Supervisor Date May 8, 2024 Project and Contract Compliance Manager Date May 8, 2024 ro ram Manager Date Senior Capital Project Officer Date May 8, 2024-- May 9, 2024 Assistant Director De t Date Director, Contractin De artment De t Date L P May 9, 2024 .1L„?i. — May 9, 2024 Assistant Ci Attorney Date Assistant City Manager Date May 13, 2024 May 17, 2024 111111rCouncl Action if re uired M&C Number ATTEST: �—a . � . Jannette Goodall, City Secretary M&C Date Approved FORT WORTH City of Fort Worth 'w, Change Order Additions Project Name 1 2023 Concrete Restoration Contract 4 I City Sec # 1 59715 1 Client Project# 1 104771 1 Contractorl Makou Inc. I PMI Marwan Hafez Inspectorl Habte Taezaz l Change Order Submittal # F3 Date 1 51312024 1 ADDITIONS ITEM DESCRIPTION DEPT 12 3305.0108 Miscellaneous Adjustment(Utilities) TPW Qty Unit Unit Cost Total 1 1.0000000E LS $20,000A $20,000.001 1 I 1 I 1 I 1 I I 1 I 1 I 1 I 1 I I 1 I 1 I 1 1 1 1 1 1 I I I 1 1 1 1 1 1 I I I 1 1 1 1 1 1 I 1 I 1 I 1 I I 1 I 1 I 1 I 1 I I 1 I 1 I 1 I T�W $20,000.001 I I I I I I Sub Total Additions $20,000.001 Change Order Additions Page 2 of 4 FOR_ T�RTH City of Fort Worth Change Order Deletions Project Name 1 2023 Concrete Restoration Contract 4 1 City Sec # 1 59715 Client Project # 1 104771 1 Contractorl Makou Inc. PMI Marwan Hafez Inspectorl Habte Taezaz Change Order Submittal # O3 Date 1 5/3/2024 DELETIONS IIEM Uh5URIF1I IUN DEFT Uty Unit Unit Cost total TPW $0.00 Sub Total Deletions $0.00 Change Order Deletions Page 3 of 4 M/SBE for this Change Order M/SBE Sub Type of Service T Amount for this CO $0.00 Total $0.00 Previous Change Orders CO # DATE I AMOUNT CO #1 9/27/2023 CO #2 3/22/2024 $33,050.00 $25,400.00 Total I $58,450.00 104771-CNCO-2023 Concrete Restoration Contract 4 Final Audit Report 2024-05-20 Created: 2024-05-08 By: Andrea Munoz (Andrea. Mu noz@fortworthtexas.gov) Status: Signed Transaction ID: CBJCHBCAABAAJiIUJ305rgFRIHaIGghjEd8gVNjrzFzl "104771-CNCO-2023 Concrete Restoration Contract 4" History Document created by Andrea Munoz (Andrea.Munoz@fortworthtexas.gov) 2024-05-08 - 6:56:51 PM GMT- IP address: 204.10.90.100 124 Document emailed to sophia.flores2@fortworthtexas.gov for filling 2024-05-08 - 7:05:13 PM GMT P4 Document emailed to makouinc@gmail.com for signature 2024-05-08 - 7:05:13 PM GMT 74 Document emailed to Habte Taezaz (Habte.Taezaz@fortworthtexas.gov) for signature `��Yz Q�1.��F:�i [�1.7 fi Kl, ►y [el �� 11 C'y Document emailed to Marwan Mohamed Saad Hafez (marwan.hafez@fortworthtexas.gov) for signature 2024-05-08 - 7:05:14 PM GMT Email viewed by makouinc@gmail.com 2024-05-08 - 7:05:18 PM GMT- IP address: 66.249.80.234 Email viewed by Marwan Mohamed Saad Hafez (marwan.hafez@fortworthtexas.gov) 2024-05-08 - 7:05:50 PM GMT- IP address: 166.205.58.39 GS© Document e-signed by Marwan Mohamed Saad Hafez (marwan.hafez@fortworthtexas.gov) Signature Date: 2024-05-08 - 7:07:12 PM GMT - Time Source: server- IP address: 166.205.58.39 Email viewed by sophia.flores2@fortworthtexas.gov 2024-05-08 - 7:09:08 PM GMT- IP address: 204.10.90.100 &,D Signer sophia.flores2@fortworthtexas.gov entered name at signing as Sophia Flores 2024-05-08 - 7:11:37 PM GMT- IP address: 204.10.90.100 FoRTWORTHs I Pawem"Y Adobe Acrobat Sign &o Form filled by Sophia Flores (sophia.flores2@fortworthtexas.gov) Form filling Date: 2024-05-08 - 7:11:39 PM GMT - Time Source: server- IP address: 204.10.90.100- Initials captured from device with phone number XXXXXXX8211 Signer makouinc@gmail.com entered name at signing as MAQSOOD KHAN 2024-05-08 - 7:14:02 PM GMT- IP address: 172.59.193.164 =, Document e-signed by MAQSOOD KHAN (makouinc@gmail.com) Signature Date: 2024-05-08 - 7:14:04 PM GMT - Time Source: server- IP address: 172.59.193.164 Email viewed by Habte Taezaz(Habte.Taezaz@fortworthtexas.gov) 2024-05-08 - 10:13:25 PM GMT- IP address: 172.59.196.20 &0 Document e-signed by Habte Taezaz(Habte.Taezaz@fortworthtexas.gov) Signature Date: 2024-05-08 - 11:52:34 PM GMT - Time Source: server- IP address: 172.59.196.20 P+ Document emailed to Zelalem Arega(Zelalem.Arega@fortworthtexas.gov) for signature 2024-05-08 - 11:52:36 PM GMT Email viewed by Zelalem Arega (Zelalem.Arega@fortworthtexas.gov) 2024-05-09 - 4:01:45 AM GMT- IP address: 99.150.144.50 &0 Document e-signed by Zelalem Arega (Zelalem.Arega@fortworthtexas.gov) Signature Date: 2024-05-09 - 4:03:35 AM GMT - Time Source: server- IP address: 99.150.144.50 C'-r Document emailed to Mary Hanna (Mary.Han na@fortworthtexas.gov) for signature 2024-05-09 - 4:03:37 AM GMT f) Email viewed by Mary Hanna (Mary.Hanna@fortworthtexas.gov) 2024-05-09 - 11:00:40 AM GMT- IP address: 99.155.57.84 GS© Document e-signed by Mary Hanna (Mary.Hanna@fortworthtexas.gov) Signature Date: 2024-05-09 - 12:39:32 PM GMT - Time Source: server- IP address: 204.10.91.100 Cy Document emailed to Patricia Wadsack (patricia.wadsack@fortworthtexas.gov) for signature 2024-05-09 - 12:39:34 PM GMT f) Email viewed by Patricia Wadsack (patricia.wadsack@fortworthtexas.gov) 2024-05-09 - 1:14:38 PM GMT- IP address: 204.10.90.100 60- Signer Patricia Wadsack (patricia.wadsack@fortworthtexas.gov) entered name at signing as Patricia L. Wadsack 2024-05-09 - 4:17:46 PM GMT- IP address: 204.10.90.100 hie Document e-signed by Patricia L. Wadsack (patricia.wadsack@fortworthtexas.gov) Signature Date: 2024-05-09 - 4:17:48 PM GMT - Time Source: server- IF address: 204.10.90.100 FoRTWORTHs I 'dbv Adobe Acrobat Sign Document emailed to Lauren Prieur (Lauren.Prieur@fortworthtexas.gov) for signature 2024-05-09 - 4:17:50 PM GMT Email viewed by Lauren Prieur (Lauren.Prieur@fortworthtexas.gov) 2024-05-09 - 4:58:22 PM GMT- IP address: 166.205.58.29 -- Document e-signed by Lauren Prieur (Lauren.Prieur@fortworthtexas.gov) Signature Date: 2024-05-09 - 6:10:04 PM GMT - Time Source: server- IP address: 107.77.199.26 Document emailed to Priscilla Ramirez (Priscilla.Ramirez@fortworthtexas.gov) for approval 2024-05-09 - 6:10:07 PM GMT Email viewed by Priscilla Ramirez (Priscilla.Ramirez@fortworthtexas.gov) 2024-05-09 - 6:43:35 PM GMT- IP address: 204.10.90.100 Document approved by Priscilla Ramirez (Priscilla.Ramirez@fortworthtexas.gov) Approval Date: 2024-05-09 - 6:43:48 PM GMT - Time Source: server- IP address: 204.10.90.100 Document emailed to Douglas Black (Douglas.Black@fortworthtexas.gov) for signature 2024-05-09 - 6:43:50 PM GMT Document e-signed by Douglas Black (Douglas.Black@fortworthtexas.gov) Signature Date: 2024-05-13 - 8:43:02 PM GMT - Time Source: server- IP address: 204.10.90.100 Document emailed to Jesica McEachern aesica.mceachern@fortworthtexas.gov) for signature 2024-05-13 - 8:43:04 PM GMT Document e-signed by Jesica McEachern Oesica.mceachern@fortworthtexas.gov) Signature Date: 2024-05-17 - 9:12:39 PM GMT - Time Source: server- IP address: 204.10.90.100 Document approval automatically delegated to Katherine Cenicola (Katherine.Cenicola@fortworthtexas.gov) by Ronald Gonzales (Ronald.Gonzales@fortworthtexas.gov) 2024-05-17 - 9:12:41 PM GMT Document emailed to Katherine Cenicola (Katherine.Cenicola@fortworthtexas.gov) for approval 2024-05-17 - 9:12:42 PM GMT Document emailed to Ronald Gonzales (Ronald.Gonzales@fortworthtexas.gov) for approval 2024-05-17 - 9:12:42 PM GMT Email viewed by Katherine Cenicola (Katherine.Cenicola@fortworthtexas.gov) 2024-05-17 - 9:50:36 PM GMT- IP address: 166.205.54.30 Document approved by Katherine Cenicola (Katherine.Cenicola@fortworthtexas.gov) Approval Date: 2024-05-17 - 9:51:00 PM GMT - Time Source: server- IP address: 166.205.54.30 FDRTWORTHs I Pave "Y Adobe Acrobat Sign Document emailed to Jannette Goodall Oannette.goodall@fortworthtexas.gov) for signature 2024-05-17 - 9:51:02 PM GMT Email viewed by Jannette Goodall Oannette.goodall@fortworthtexas.gov) 2024-05-17 - 9:58:33 PM GMT- IP address: 204.10.90.100 -- Document e-signed by Jannette Goodall Qannette.goodall@fortworthtexas.gov) Signature Date: 2024-05-17 - 9:58:45 PM GMT - Time Source: server- IP address: 204.10.90.100 Form filling automatically delegated to Elisa Winterrowd (Elisa.Winterrowd@fortworthtexas.gov) by Allison Tidwell (allison.tidwell@fortworthtexas.gov) 2024-05-17 - 9:58:47 PM GMT Py Document emailed to Elisa Winterrowd (Elisa.Winterrowd@fortworthtexas.gov) for filling 2024-05-17 - 9:58:47 PM GMT P+ Document emailed to Allison Tidwell (allison.tidwell@fortworthtexas.gov) for filling 2024-05-17 - 9:58:47 PM GMT &o Form filled by Elisa Winterrowd (Elisa.Winterrowd@fortworthtexas.gov) Form filling Date: 2024-05-20 - 2:20:41 PM GMT - Time Source: server- IP address: 204.10.90.100 0 Agreement completed. 2024-05-20 - 2:20:41 PM GMT FoRTWORTHs I Paw m"Y Adobe Acrobat Sign FORTWORTH. TRANSPORTATION AND PUBLIC WORKS August 1, 2024 Makou Inc. 7100 Cooper Street #5 Arlington, TX 76001 RE: Acceptance Letter Project Name: 2023 Concrete Restoration Contract 4 at Variuos Locations Project Type: Paving City Project No.: 104771 To Whom It May Concern: On May 30, 2024 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 August 1, 2024. 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 August 1, 2024, 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- 392-7968. Sincerely, Marwan Hafez, Project Manager Cc: Habte Taezaz, Inspector Troy Gardner, Inspection Supervisor Ariel Duarte, Senior Inspector Zalalem Arega, Program Manager SAM, Consultant Makou Inc., Contractor City Fort Worth, Developer File E-Mail: TPW_Acceptance@fortworthtexas.gov Rev. 8/20/19 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 Maqsood Khan, Owner of MAKOU INC., known to me to be credible person, who being 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, for City of Fort Worth Conc. Rest. 2023-4 Project# 104771 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 BY--- - ------------------------------------- MAQSO D KHAN, PRINCIPAL, MAKOU INC. SUBSCIBED & SWORN BY ME ON THIS DATE NOT Y PUBLIC TEXAS BRITT SMITH .�pPY PL'i =r'' °�%Notary Public, State of Texas = Comm. Expires 04-30-2025 oF.` Notary ID 12322042 MAKOU Inc. 7100 S. Cooper St. Suite #15 Arlington, TX 76001 ::.... _,... .. 817-798-5426 Boren #: 4912740 CONSENT OF SURETY TO FINAL PAYMENT AIA Document G707 (Instructions on reverse side) TO OWNER: (Name and addressJ City of Fort Worth OWNER ARCHITECT CONTRACTOR SURETY OTHER ARCHITECT'S PROJECT NO.: CONTRACT FOR: PROJECT: CONTRACT DATED: June 13, 2023 (Name and address) 2023 Concrete Restoration Contract 4, City Project No. 104771 In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above, the (Insert name and address of Surety) Great American Insurance Company 301 E. 4th Street Cincinnati, Ohio 45202 on bond of (Insert name and address of Contractor) Makou, Inc 6204 Parkside Dr Arlington, TX 76001 N El ,SURETY, .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 as set forth in said Surety's bond, IN WITNESS WHEREOF, the Surety has hereunto set its hand on this date: ,July 29, 2024 (Insert in writing the month followed by the numeric date and year) Attest: (MP (Seal): A Great American Insurance Company (Surety) (Signature of-,th.,,—d representative) Brent M. Blonigan, Attorney -in -fact (Printed name and title) , OWNER, CAUTION: You should sign an original AIA document that has this caution printed in red. An original assures that changes will not be obscured as may occur when documents are reproduced. See Instruction Sheet for Limited License for Reproduction of this document. AIA DOCUMENT G707 -CONSENT OF SURETY TO FINAL PAYMENT-1994 EDITION - AIA 1994 - THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, NW, WASH- INGTON, D.C. 20006-5292 - WARNING: Unlicensed photocopying violates U.S. copy- right laws and will subject the violator to legal proseoution. Page 1 of 2 G707-1994 INSTRUCTION SHEET FOR AIA DOCUMENT G707, 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 construction projects where the Contractor is required to furnish a bond. By obtaining the Surety's approval of final payment to the Contractor and its agreement that final payment will not 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 the 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 ALA 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 further rights to reproduce G707. A cautionary notice is printed in red on the original of this document. This notice distinguishes 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 special 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 reproductions are prohibited without the express permission of the 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 Surety, Owner, Contractor and Project. ARCHITECT'S PROJECT NO.: this information is typically supplied by the Architect and entered on the form by the Contractor_ CONTRACT FOR: This refers to the scope of the 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 INSTRUCTION SHEET FOR AIA DOCUMENT G707 0 CONSENT OF SURETY TO FINAL PAYMENT 01994 EDITIONO MA®O THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006-5292 Page 2 of 2 G707-1994 GREAT AMERICAN INSURANCE COMPANY® Administrative Office: 301 E 4TH STREET • CINCINNATI, OHIO 45202 • 513-369-5000 • FAX 513-723-2740 The number of persons authorized by this power of attorney is not more than Five POWER OF ATTORNEY No. 0 21868 KNOW ALL MEN BY THESE PRESENTS: That the GREAT AMERICAN INSURANCE COMPANY, a corporation organized and existing under and by virtue of the laws of the State of Ohio, does hereby nominate, constitute and appoint the person or persons named below, each individually if more than one is named, its true and lawful attorney -in -fact, for it and in its name, place and stead to execute on behalf of the said Company, as surety, any and all bonds, undertakings and contracts of suretyship, or other written obligations in the nature thereof; provided that the liability of the said Company on any such bond, undertaking or contract of suretyship executed under this authority shall not exceed the limit stated below. Name Brent M. Blonigan Raul F. Campa Rob Dreiling Debbie Palmer Kara Pierce Address All of Richardson, Texas Limit of Power All $100,000,000 This Power of Attorney revokes all previous powers issued on behalf of the attorney(s)-in-fact named above. IN WITNESS WHEREOF the GREAT AMERICAN INSURANCE COMPANY has caused these presents to be signed and attested by its appropriate officers and its corporate seal hereunto affixed this 14th day of July 2021 Attest GREAT AMERICAN INSURANCE COMPANY fir..-•., � � � J Assivani Sec•retan Divisional Senior Vice President STATE OF OHIO, COUNTY OF HAMILTON - ss: MARK vICAR10 (e77-377.2405) On this 14th day of July 2021 , before me personally appeared MARK VICARIO, to me known, being duly swom, deposes and says that he resides in Cincinnati, Ohio, that he is a Divisional Senior Vice President of the Bond Division of Great American Insurance Company, the Company described in and which executed the above instrument; that he knows the seal of the said Company; that the seal affixed to the said instrument is such corporate seal; that it was so affixed by authority of his office under the By -Laws of said Company, and that he signed his name thereto by like authority. SUSAN A KOHORST r, notary Public State of Ohio My Comm. Expires May 18, 2025 'S'., IQ '14'xtay This Power of Attorney is granted by authority of the following resolutions adopted by the Board of Directors of Great American Insurance Company by unanimous written consent dated June 9, 2008. RESOLVED: That the Divisional President, the several Divisional Senior Vice Presidents. Divisional Vice Presidents and Divisonal Assistant lice Presidents, or any one of them, he and hereby is mtthori2ed, frtnn time to time, to appoint one or more Attornevs-in-Fact to execute on behalf of the Company, as surety, arty and all bonds, undertakings and contracts of suretyship, or other written obligations in the nature thereof, to prescribe their respective duties and the respective limits of their authority, and to revoke anv such appointment at at?v time. RESOLVED FURTHER: That the Company seal and the signature of any of the aforesaid officers and anv Secretary or Assistant Secretary of the Company may be affixed by facsimile to any power of attorney or certificate of either given for the execution of any bond, undertaking, contract of suretyship, or other written obligation in the nature thereof. such signature and seal when so used being herehy adopted by the Company as the original signature of such officer and the original seal of die Company, to be valid and binding upon the Compam• with the same force and effect as though manually a -fed CERTIFICATION 1, STEPHEN C. BERAHA, Assistant Secretary of Great American Insurance Company, do hereby certify that the foregoing Power of Attorney and the Resolutions of the Board of Directors of June 9, 2008 have not een revoked and are now in frill force and effect. Signed and sealed this day of Assistant Secrerary S1029AH (03/20) Great American Alliance Insurance Company GREAIAMERICAN Great American Insurance Company INSURANCE GROUP IMPORTANT NOTICE: To obtain information or make a complaint: You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1-800-252-3439 You may write the Texas Department of Insurance at: P.O. Box 149104 Austin, TX 78714-9091 FAX: 1-512-490-1007 Your notice of claim against the attached bond may be given to the surety company that issued the bond by sending it by certified or registered mail to the following address: Mailing Address: Great American Insurance Company P.O. Box 2119 Cincinnati, Ohio 45202 Physical Address: Great American Insurance Company 301 E. Fourth Street Cincinnati, Ohio 45202 You may also contact the Great American Insurance Company Claim office by: Fax:, 1-888-290-3706 Telephone: 1-513-369-5091 Email: bondclaims@gaic.com PREMIUM OR CLAIM DISPUTES: If you have a dispute concerning a premium, you should contact the agent first. If you have a dispute conceming a claim, you should contact the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR BOND: This notice is for information only and does not become a part or condition of the attached document. F.9667A (10l16)