HomeMy WebLinkAboutContract 55815-FP1FORT WORTH.
-FP1
City Secretary 55815
Contract No.
Date Received 11/7/2024
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: 901 Commerce Street
City Project No.: 101499
Improvement Type(s): x❑ Paving ODrainage ❑x Street Lights
Original Contract Price: $627,931.33
Amount of Approved Change Order(s) - $-68,524.90
Revised Contract Amount: $559,406.43
Total Cost of Work Com plete: $559,406.43
ErikKrupp4.� Nov 6, 2024
Contractor Date
Executive Vice President
Title
SLC Commercial Construction LLC
Company Name
Nov 7, 2024
.lce(Nov7.202409:06CST)
Project Inspector
Date
9
Nov 7, 2024
Project Manager
Date
Nov 7, 2024
Rebecca Owen Mov 7.202410:00 CST)
CFA Manager
Date
All--�
Nov 7, 2024
TPW Director
Date
Nov 8, 2024
Asst. City Manager
Date
❑X Landscaping
OFFICIAL RECORD
CITY SECRETARY Page 1 of 2
FT. WORTH, TX
Notice of Project Completion
Project Name: 901 Commerce Street
City Project No.: 101499
City's Attachments
Final Pay Estimate ❑x
Change Order(s): ❑x Yes ❑ N/A
Contractor's Attachments
Affidavit of Bills Paid
Consent of Surety
Statement of Contract Time
Statement of Contract Time
Contract Time: 60 WD Days Charged: 324 WD
Work Start Date: 7/19/2021 Work Complete Date: 5/29/2024
Completed number of Soil Lab Test: 81
Completed number of Water Test: 6
Page 2of2
FoRTWORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEMEN
Contract Limits
Project Type PAVING & STREET LIGHTS
City Project Numbers 101499
DOE Number 1499
Estimate Number 1 Payment Number 1 For Period Ending 5/29/2024
WD
City Secretary Contract Number Contract Time 6WD
Contract Date Days Charged to Date 324
Project Manager NA Contract is 100.00 Complete
Contractor SLC COMMERCIAL CONSTRUCTION, LLC
3990 HILLSBORO PIKE, SUITE 400
NASHVILLE , TN 37215
Inspectors G.DEYON / J.KOONCE
Tuesday, November 5, 2024 Page 1 of 5
City Project Numbers 101499 DOE Number 1499
Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEME Estimate Number I
Contract Limits Payment Number 1
Project Type PAVING & STREET LIGHTS For Period Ending 5/29/2024
Project Funding
UNIT lII: PAVING IMPROVEMENTS
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
CONSTRUCTION STAKING
1 LS
$5,255.08
$5,255.08
1
$5,255.08
2
REMOVE SIDEWALK
8097 SF
$8.16
$66,071.52
8097
$66,071.52
3
REMOVE ADA RAMP
3 EA
$729.87
$2,189.61
3
$2,189.61
4
REMOVE CONCRETE DRIVE
277 SF
$1.22
$337.94
277
$337.94
5
REMOVE ASPHALT PVMT
170 SY
$94.88
$16,129.60
170
$16,129.60
6
REMOVE CONC CURB & GUTTER
200 LF
$11.87
$2,374.00
200
$2,374.00
7
3" SURFACE MILLING
7410 SY
$15.50
$114,855.00
7410
$114,855.00
8
SWPPP 1 ACRE
1 LS
$8,787.66
$8,787.66
1
$8,787.66
9
Y ASPHALT PVMT TYPE D (CO#1)
7415 SY
$5.42
$40,189.30
7415
$40,189.30
10
6" CONCRETE DRIVEWAY
72 SF
$11.54
$830.88
72
$830.88
11
4" CONC SIDEWALK (CO#1)
4283 SF
$10.76
$46,085.08
4283
$46,085.08
12
BARRIER FREE RAMP TYPE M-1 (CO#1)
4 EA
$1,888.52
$7,554.08
4
$7,554.08
13
6" CONC CURB AND GUTTER
234 LF
$35.99
$8,421.66
234
$8,421.66
14
4" SLD PVMT MARKING HAS (W)
10 LF
$7.30
$73.00
10
$73.00
15
12" SLD PVMT MARKING HAE (W)
60 LF
$21.90
$1,314.00
60
$1,314.00
16
24" SLD PVMT MARKING HAE (W)
30 LF
$43.79
$1,313.70
30
$1,313.70
17
FURNISH/INSTALL ALUM SIGN GROUND
4 EA
$948.83
$3,795.32
4
$3,795.32
MOUNT CITY STD.
18
REMOVE AND REINSTALL SIGN PANEL AND
5 EA
$437.95
$2,189.75
5
$2,189.75
POST
19
TRAFFIC CONTROL
I MO
$5,249.24
$5,249.24
1
$5,249.24
20
SIDEWALK (BRICK PAVERS)
2831 SF
$27.95
$79,126.45
2831
$79,126.45
21
CONNECT TO PUBLIC STORM SYSTEM
3 EA
$2,500.00
$7,500.00
3
$7,500.00
22
PARKING METER STEEL POST (METER
3 EA
$365.05
$1,095.15
3
$1,095.15
INSTALLED BY CITY)
-------------
Sub -Total of Previous
Unit
$420,738.02
$420,738.02
UNIT IV: LIGHTING IMPROVEMENTS
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
---------------------------------------
1
2" CONDT PVC SCH 80 (T)
1419 LF
$20.44
$29,004.36
1419
$29,004.36
2
EXPLORATORY EXCAVATION OF EXISTING
5 EA
$656.89
$3,284.45
5
$3,284.45
UTLITIES
Tuesday, November 5, 2024 Page 2 of 5
City Project Numbers 101499 DOE Number 1499
Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEME Estimate Number I
Contract Limits Payment Number 1
Project Type PAVING, STREET LIGHTS, LANDSCAPING For Period Ending 5/29/2024
Project Funding
3
NO 8 INSULATED ELEC CONDR
4565 LF
$6.57
$29,992.05
4565
$29,992.05
4
GROUND BOX TYPE B
5 EA
$1,094.81
$5,474.05
5
$5,474.05
5
FURNISH/INSTALL CITY HALL POLE AND
2 EA
$6,272.52
$12,545.04
2
$12,545.04
LUMINAIRE
6
FURNISH/INSTALL UTILITY WASHINGTON
5 EA
$7,066.62
$35,333.10
5
$35,333.10
POSTLITE SERIES LUMINAIRE FULL CUTOFF
7
LED LIGHTING FIXTURE
1 EA
$875.84
$875.84
1
$875.84
8
RDWY ILLUM FOUNDATION TY 7
5 EA
$1,600.00
$8,000.00
5
$8,000.00
9
SALVAGE STREET LIGHT POLE
4 EA
$2,627.54
$10,510.16
4
$10,510.16
10
TRAFFIC CONTROL
1 MO
$3,649.36
$3,649.36
1
$3,649.36
Sub -Total of Previous
Unit
$138,668.41
$138,668.41
- - - - - - - - - - - - - - - -
UNrr V: LANDSCAPE IMPROVEMENTS
- - -
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
---------------------------------------
1
6"-12" TREE REMOVAL (CO#1)
0 EA
$510.91
$0.00
0
$0.00
2
PLANT 6" TREE (CO#I)
0 EA
$1,921.00
$0.00
0
$0.00
3
SALVAGE EXISTING TRASH CAN (CO#1)
0 EA
$145.95
$0.00
0
$0.00
4
48" SQUARE TREE GRATE (CO#1)
0 EA
$2,345.00
$0.00
0
$0.00
Sub -Total of Previous
Unit
$0.00
$0.00
Tuesday, November 5, 2024 Page 3 of 5
City Project Numbers 101499 DOE Number 1499
Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEME Estimate Number I
Contract Limits Payment Number 1
Project Type LANDSCAPING For Period Ending 5/29/2024
Project Funding
Contract Information Summary
Original Contract Amount $627,931.33
Change Orders
Change Order Number 1 $3,088.46
Change Order Number 1 ($71,613.36)
Total Contract Price $559,406.43
Total Cost of Work Completed $559,406.43
Less % Retained $0.00
Net Earned $559,406.43
Earned This Period $559,406.43
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
$559,406.43
Tuesday, November 5, 2024 Page 4 of 5
City Project Numbers 101499 DOE Number 1499
Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEME Estimate Number I
Contract Limits Payment Number 1
Project Type LANDSCAPING For Period Ending 5/29/2024
Project Funding
Project Manager NA
Inspectors G.DEYON / J.KOONCE
Contractor SLC COMMERCIAL CONSTRUCTION, LLC
3990 HILLSBORO PIKE, SUITE 400
NASHVILLE , IN 37215
City Secretary Contract Number
Contract Date
Contract Time 60 WD
Days Charged to Date 324WD
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 $559,406.43
Less % Retained $0.00
Net Earned $559,406.43
Earned This Period $559,406.43
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
$559,406.43
Tuesday, November 5, 2024 Page 5 of 5
PROJECT NAME:
CONTRACT:
CFA #
CITY PROJECT #
DOE #
WATER PROJECT #
SEWER PROJECT #
FILE #
INSPECTOR:
PROJECT MANAGER
DEVELOPER -AWARDED -PROJECT CHANGE ORDER
WATER, SANITARY SEWER, PAVING, AND STREET LIGHT IMPROVEMENTS TO
SERVE 901 COMMERCE STREET
CHANGE
CS-55815
ORDER No:
CFA19-0111
CITY PARTICIPATION: I NO
101499
NA
56008-0600430-101499-001580
56008-0700430-101499-001380
K-2753, X-26477
JEREMY KOONCE
Phone No: 832.527.5406
REVIEWED
DEBBIE J. W ILLHELM, PE
Phone No: 817.392.2481
By Debbie J. Willhelm at 3:20 pm, May 29, 2024
WATER
Cost I
City Cost
ORIGINAL CONTRACT
$176,260.00 I
$0.00
EXTRAS TO DATE
$0.00 I
$0.00
CREDITS TO DATE
$0.00 I
$0.00
CONTRACT TO DATE
$176,260.00 I
$0.00
AMOUNT OF PROP. CHANGE ORDER
$0.00 I
$0.00
REVISED CONTRACT AMOUNT
$176,260.00 I
$0.00
TOTAL REVISED CONTRACT AMOUNT
PER UNIT
$176,260.00
REVISED COST SHARE
Dev. Cost:
TOTAL REVISED CONTRACT
CONTRACT UNIT
SEWER PAVING STREET LIGHTS LANDSCAPE
;ost
City Cost
Cost
City Cost
$142,972.00
$0.00
$417,649.56
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$142,972.00
$0.00
$417,649.56
$0.00
$ 154,343.81
$0.00
$ 3,088.46
$0.00
$297,315.81
$0.00
$420,738.02
$297,315.81
$420,738.02
$1,032,982.24
City Cost:
$1, 032,982.24
leveloper Developer
:ost City Cost Cost
$138,668.41 I $0.00 I $71,613.36
$0.00 $0.00 I $0.00
$0.00 $0.00 I $0.00
$138,668.41 $0.00 I $71,613.36
$0.00 I $0.00 I-71,613.36
$138,668.41 $0.00 I $0.00
$138,668.41 $0.00
$0.00
ty Cost
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
WORKING
DAYS
60
0
0
60
0
60
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 ITEM DESCRIPTION UNIT PRICE I TOTAL
UNIT II: SANITARY SEWER IMPROVEMENTS
3
0241.2201
-1
EA
REMOVE 4' SEWER MANHOLE
$
2,500.00
$ (2,500.00)
16
3339.1101
-1
EA
5' MANHOLE
$
17,400.00
$ (17,400.00)
17
3339.1103
-7
VF
5' EXTRA DEPTH MANHOLE
$
310.00
$ (2,170.00)
NEW ITEM
3305.0114
1
EA
MANHOLE ADJUSTMENT, MAJOR W/ COVER
$
19,413.81
$ 19,413.81
NEW ITEM
3303.0001
1
LS
BYPASS PUMPING
$
157,000.00
$157,000.00
SANITARY SEWER IMPROVEMENTS SUBTOTAL
$154,343.81
UNIT III: PAVING IMPROVEMENTS
9
3212.0303
5
SY
3" ASPHALT PVMT TYPE ID$
5.42
$ 27.10
11
3213.0301
109
SF
4" CONCRETE SIDEWALK
$
10.76
$ 1,172.84
12
3213.0503
1
EA
BARRIER FREE RAMP, TYPE M-1
$
1,888.52
$ 1,888.52
� 1
2
3
4
REASONS FOR CHANGE ORDER
PAVING IMPROVEMENTS SUBTOTALS $ 3,088.46
UNIT V: LANDSCAPE IMPROVEMENTS
3110.0102 -6 EA 6"-12" TREE REMOVAL $ 510.91 $ (3,065.46)
3293.0106 -16 EA PLANT 6" TREE $ 1,921.00 $ (30,736.00)
9999.0002 -2 EA SALVAGE EXISTING TRASH CAN $ 145.95 $ (291.90)
9999.0005 -16 EA 48" SQUARE TREE GRATE $ 2,345.00 $ (37,520.00)
LANDSCAPE IMPROVEMENTS SUBTOTAL $ (71,613.36)
GRAND TOTAL $ 85,818.91
EXISTING SSMH AT 8TH AND COMMERCE STREET WAS STRUCTURALLY SOUND; ONLY NEEDED TO REPLACE THE MANHOLE CONE, RING, &
COVER. BY-PASS PUMPING LINE ITEM WAS ALSO ADDED TO FACILITATE CONSTRUCTION OF SS LINE A. CHANGES CORRESPOND TO REVISION
NO. 1 AS SHOWN ON SHEETS C1.00, C1.01, C1.02 AND C1.04 OF THE CONSTRUCTION PLANS.
CHANGE ORDER NEEDED TO REPLACE THE EXISTING ADA RAMP AND SURROUNDING ASPHALT PAVEMENT AT THE SOUTHEAST CORNER OF
CALHOUN STREET AND EAST 8TH STREET. CHANGES CORRESPOND TO REVISION NO. 1 AS SHOWN ON SHEETS C2.00 AND C3.00 OF THE
CONSTRUCTION PLANS.
REMOVING LANDSCAPING ITEMS FROM THE CFA; THESE ITEMS ARE NOT CITY ASSETS. THESE ITEMS WILL BE COORDINATED AND MAINTAINED
BY THE OWNER.
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:
APPROVED:
KIMLEY-HORN AND ASSOCIATES, INC 9TH AND COMMERCE FORT WORTH, LLC
By:
Name: Brandon Middleton
Title: Civil Engineer
DocuSigned by:
B:
Name:
Title: President
APPROVED:
SLC COMMERCIAL CONSTRUCTION, LLC
DocuSigned by:
B �l 74
Name: DES K"Offop
Title: EVP - commercial construction
Revised: 10-12-2011 Page 2
FORTWORTH.
TRANSPORTATION AND PUBLIC WORKS
June 5, 2024
SLC Commercial Construction LLC
3990 Hillsboro Pike, Suite 400
Nashville, TN 37215
RE: Acceptance Letter
Project Name: 901 Commerce Street
Project Type: Developer
City Project No.: 101499
To Whom It May Concern:
On May 28, 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 May 29, 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 May 29, 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
(832)527-5406.
Sincerely,
DebbieOOWillhelm, Project Manager
Cc: Jeremy Koonce, Inspector
Lorrie Pitts, Inspection Supervisor
Gary Deyon, Senior Inspector
Andrew Goodman, Program Manager
Kimley Horn, Consultant
Southern Land Company, Contractor
Southern Land Company, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev. 8/20/19
SLC COMMERCIAL CONSTRUCTION, LLC
3990 Hillsboro Pike, Suite 400
Nashville, TN 37215
October 30, 2024
City of Fort Worth
CFA Administration
200 Texas St.
Fort Worth, TX 76102
RE: 901 Commerce (Deco 969); 969 Commerce Street, Fort Worth, TX
CFA No.:
CFA19-0111
City Project No.:
101499
IPRC No.:
19-0156
City Contract No.:
55815
COMPONENTS: Water, Sewer, Paving, Street Lights
The purpose of this letter is to acknowledge that SLC Commercial Construction, LLC has been
paid in full by 9th and Commerce Fort Worth, LLC c/o Southern Land Company for the public
improvements constructed to serve 901 Commerce in Fort Worth, Texas. As a result, we hereby
waive, release and relinquish all rights to assert any claim or demand for lien in connection with
this project.
Please feel free to contact me with any questions you may have.
Sincerely,
SLC COMMERCIAL CONSTRUCTION, LLC
By: ail
Name: ;-rr-' ,Vo-ye
Title: 'pLkf, A e5-1-6 -
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Bond No. 60141361
SECTION 00 62 19
MAINTENANCE BOND
THE STATE OF TEXAS §
§ KNOW ALL BY THESE PRESENTS:
CO U NTY OF TARRANT §
006219-1
MAINTENANCE BOND
Page 1 of 3
That we SLC COMMERCIAL CONSTRUCTION, LLC, known as "Principal" herein and CAPITOL
INDEMNITY CORPORATION, a corporate surety (sureties, if more than one) duly authorized to do
business in the State of Texas, known as "Surety" herein (whether one or more), are held and
firmly bound unto the Developer, 9TH AND COMMERCE FORT WORTH, LLC, authorized to do
business in Texas ("Developer") and the City of Fort Worth, a Texas municipal corporation
("City"), in the sum of Nine Hundred Fortv-Seven Thousand One Hundred Sixtv-Three and
33 100 DOLLARS ($947,163.33), lawful money of the United States, to be paid in Fort Worth,
Tarrant County, Texas, for payment of which sum well and truly be made jointly unto the
Developer and the City as dual obligees and their successors, we bind ourselves, our heirs,
executors, administrators, successors and assigns, jointly and severally, firmly by these presents.
18 WHEREAS, Developer and City have entered into an Agreement for the construction of
19 community facilities in the City of Fort Worth by and through a Community Facilities Agreement,
20 CFA Number CFA19-0111; and
21 WHEREAS, the Principal has entered into a certain written contract with the Developer
22 awarded the day of , 2021, which Contract is hereby
23 referred to and a made part hereof for all purposes as if fully set forth herein, to furnish all
24 materials, equipment labor and other accessories as defined by law, in the prosecution of the
25 Work, including any Work resulting from a duly authorized Change Order (collectively herein,
26 the "Work") as provided for in said Contract and designated as WATER, SANITARY SEWER,
27 PAVING, AND STREET LIGHT IMPROVEMENTS TO SERVE 901 COMMERCE STREET; and
28
CITY OF FORT WORTH IPRC19-0156
STANDARD CITY CONDITIONS — DEVELOPER AWARDED PROJECTSCITY PROJECT NO. 101499
Revised January 31, 2012
006219-2
MAINTENANCE BOND
Page 2 of 3
1 WHEREAS, Principal binds itself to use such materials and to so construct the Work in
2 accordance with the plans, specifications and Contract Documents that the Work is and will
3 remain free from defects in materials or workmanship for and during the period of two (2) years
4 after the date of Final Acceptance of the Work by the City ("Maintenance Period"); and
5 WHEREAS, Principal binds itself to repair or reconstruct the Work in whole or in part upon
6 receiving notice from the Developer and/or City of the need thereof at any time within the
7 Maintenance Period.
S NOW THEREFORE, the condition of this obligation is such that if Principal shall remedy
9 any defective Work, for which timely notice was provided by Developer or City, to a completion
10 satisfactory to the City, then this obligation shall become null and void; otherwise to remain in
11 full force and effect.
12 PROVIDED, HOWEVER, if Principal shall fail so to repair or reconstruct any timely
13 noticed defective Work, it is agreed that the Developer or City may cause any and all such
14 defective Work to be repaired and/or reconstructed with all associated costs thereof being
15 borne by the Principal and the Surety under this Maintenance Bond; and
16 PROVIDED FURTHER, that if any legal action be filed on this Bond, venue shall lie in
17 Tarrant County, Texas or the United States District Court for the Northern District of Texas, Fort
18 Worth Division; and
19 PROVIDED FURTHER, that this obligation shall be continuous in nature and successive
20 recoveries may be had hereon for successive breaches.
21
CITY OF FORT WORTH 1PRC19-0156
STANDARD CITY CONDITIONS —DEVELOPER AWARDED PROJECTSCITY PROJECT NO. IOJ499
Revised January 31, 2012
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006219-3
MAINTENANCE BOND
Page 3 of 3
IN WITNESS WHEREOF, the Principal and the Surety have each SIGNED and SEALED this
instrument by duly authorized agents and officers on this the 29th day of April, 2021.
ATTEST:
---114
(Principaff Secretary
ff14F_X
Witness as to PKcipal
nJrwAAA-) tom- -m s
A
I
ATTEST:
(Surety) L'Witness
Witness as to St
PRINCIPAL:
SLC COM RICAL ON UCTION, LLC
BY:
Signatur
014 C F
Name andKtle v
Address: 3990 Hillsboro Pike, Suite 400
Nashville, TN 37125
SURETY:
CAPITOL JVINITY CO P6AATION
BY:
Si ture
V
Phyllis T. Neal, Attorney -in -Fact
Name and Title
Address: 1600 Aspen Commons, Suite 300
Middleton, WI 53562
Telephone Number: 800-475-4450
37 *Note: If signed b an o cer of the Surety Company, there must be on file a certified extract
38 from the by- s showing that this person has authority to sign such obligation. If
39 Surety's physical address is different from its mailing address, both must be provided.
CITY OF FORT WORTH IPRC19-0156
STANDARD CITY CONDITIONS — DEVELOPER AWARDED PROJECTSCITY PROJECT NO. 101499
Revised January 31, 2012
3
006219-4
MAINTENANCE BOND
Page 4 of 3
The date of the bond shall not be prior to the date the Contract is awarded.
CITY OF FORT WORTH IPRC19-0156
STAN DARD CITY CONDITIONS — DEVELOPER AWARDED PROD ECTSCITY PROJECT NO. 101499
Rewsed January 31, 2012
CAPITOL INDEMNITY CORPORATION 60141361
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, That the CAPII'OL INDENIN'IT7- CORPORA-r10N, a corl,kration of the State of Witic mMlll. ba: I}s;=_
its poncipei offices in the City of Middleton. Wisconsin. lines make. romtitute and -appoint
--------------------ROBERT E, GIGAX, JR.; SHELLY M. MARTIN; PHYLLIS T. NEAL
its true and lawful Altorncy(s)-in-fact, to make, exe.cutc, seal and deliver far and on it% behatf, as surety, and as its act and deed- any and all bonds. undemikin ,,
and contracrs of Suretyship. provided that no bond or undertaking or contract of suretyship executed tmder this authoray shall eRcccd in aniYiunt tl-Si' sttnl ..,I
----------------------------AL,L WRITTEN INSTRUMENTS 1N AN AMOUNT NOT TO EXCEED:$20,000,000,00-------------------------- -----
This Power of A€torney is granted and is swned and waled by facsnhhi}c under anJ t y rile ,authority of the tollmcing Rcsolnl inn adoptcdi h' the BoLi -d of
Directors of CAPITOL 1NDEMNi'i'Y CORPORAI'ION at a meetin, duly called and held on the tith day of fanuary. 2002.
"RESOLVED, that the President. Executive Vice President, Vice President, Seerc:utry or Treasurer. acting individually or ntberwi e, be and 1'he;y hcrehy'
arc ,rimed the power and authorization to appoint by a Power of Attorney for the purpokes only of executing and atteStia; bunds and Rnd'Crttilcing,. and
ocher w'riongs obligatory In the nature thereof, tine or more resident vice-pwsidents, assistatit secretaries anal alLaniey(s}-lit-fillet, 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 Compimy may be affixed to any
Such power of attorney or to any certificate relatnie thereto by facsimile. tied any .such power of attorney or certificaie hearing such facsimile signatures
or facsimile seal shall be valid and binding upon the Company, and any Such power so executed anti cetliftad by facsimile signatures and facsimile seal
shall be valid and binding upon the Company in the future with respect to any bond or undertakufe or other writing obligatory in the nautrc iherea.if to
which it is attached. Any such appoinimerit may he revoked, for cause, or withouteausv' by anv of said officers, ai any tinic:'
In connection with obligations in favor of the Florida Department of Transportation only. it is agreed that the power and ,thorny hereby given to the
Attorney -in -Fact includes any and all consents for the release of retained percertta,e9'aind/or Cilia] estimates on engineering and construction Wiitrack
required by the State of Florida Department of Transportation. It is fully understixtd that consenting to the State of Floltda Deprirmient of Transportation
making payment of the final estimate to the Contractor and/or its assitinec, shall not relieve this surety company of anyof its oblikatiims tnidel it', bond.
In connection with obligations in favor of the Kentucky Department of Highways only. it is :greed that the power and authority hereby given to the
Attorney -in -Fria cannot be modified or revoked unless prior written personal notice of such intent has been given to the Contmi sioner - Deportinent of
Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the mad.ification or revocation.
IN WITNESS WHEREOF. the CAPITOL. INDEMNITY CORPORATiON has caused these presen(% to be signed by its trfficer undersigned and it,
corporate seal to be hereto affixed duly at£emed, this 3rd day of May, 2017.
Attest: �J
CAPITOL INnE'~INrn, CORPORATION
V0\�`aU1�VINOII]II/rr�,Oppf.»
x�4\O 0v...
pFrPOf
,_
John E. Rzepin— ski _ — • c
Vice President, Treasurer b CFO 6- Stephen _ Stephen J ':ill+
1i SEL4tCEO iS President
Suzanne M. Broadbent ��!r�iurl�tilllli�uu�ui���0
Assistant Secretary
SI'ATE OF W ISCONSIN
COUNTY OF DANE
On the 3rd day of May, 2017 hefore me personally came Stephen .l. Sills, to me known. who being by me duly sworn, did depose and sa}'c that he rcNi&,"
in the County of New York, State of New York: that he is President of CAPITOL. INDEMNITY CORPORATION, the corpor.uiun drsL:rilwd 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 sea]: that it
was so affixed by order of the Board of Directors of said. corporation and that he signed his n:une thereto by like order.
g; 9�LC'y Davit. .I. Re,el'e
STATE OF WISCONSIN ''-< --���{�'�5 Notary Public. Dane Co., Wi
6,/�kuip x
COUNTY OF DANE My Commission is Permanent
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 foregoin attached. Power of Anorucv remains in full l'orce and has not been
revoked; €ind furthermore, that the Resolution of the Board of Directors, set forth in the Power of Attorney is not in force.
Sietied and settled A the City of Middleton. State of Wisconsin this _29th day of Anti 1 20 21
I ' `S A 1 C\A� l.11.�lJu.
Antonin Celli
is General Counsel, Vice President Secretary
THIS DOCUMENT IS NOT VAI 111 UNLESS PRINTED ON GRAY `HADED BACKGRoLIND WITH A RED SERIAL NUMBER IN THE UIPPLR R10H r HAND
CORNER IF YOU HAVE. ANYQJ+STIONSCONCERNiNGTHEAUl`iGVTICITYOFrim DOCUMENI-CALL80o--l7i-4450 CiL-110s(Re,.u,-20t11
CAPITOL INDEMNITY CORPORATION
BALANCE SHEET
December 3i, 2020
Admitted Assets
Cash and invested assets:
Bonds $ 540,050,945
Common stocks 136,823,713
Cash, cash equivalents and short-term investments 51,386,666
Other invested assets 74,185
Receivables for securities 7,139
Total cash and invested assets 728,342,648
Investment income due and accrued
3,025,223
Uncollected premiums and agents' balances in course of collection
43,072,989
Deferred premiums, agents' balances and installments booked but deferred and not yet due
9,868,137
Amounts recoverable from reinsurers
5,847,405
Other amounts receivable under reinsurance contracts
97,063
Current federal and foreign income tax recoverable and interest thereon
363,716
Net deferred tax asset
15,146,078
Electronic data processing equipment and software
1,890,377
Receivables from parent, subsidiaries and affiliates
39,560
Total admitted assets
$ 807,693,196
Liabilities and Surplus as Regards Policyholders
Liabilities:
Losses
$ 275,220,050
Reinsurance payable on paid losses and loss adjustment expenses
17,552,032
Loss adjustment expenses
54,378,410
Commissions payable, contingent commissions and other similar charges
434,788
Other expenses f excluding taxes, licenses and fees)
8,989,870
Taxes, licenses and fees (excluding federal and foreign income taxes)
580,794
Unearned premiums
136,642,443
Advance Premium
5,481
Ceded reinsurance premiums payable (net of ceding commissions)
4,835,724
Amounts withheld or retained by company for account of others
11,806,760
Provision for reinsurance
208,000
Payable to parent, subsidiaries and affiliates
16,308,674
Payable for securities
313
Other liabilities
561,483
Total liabilities
527,523,822
Surplus as regards policyholders:
Common capital stock
4,201,416
Gross paid in and contributed surplus
103,923,753
Unassigned funds (surplus)
172,044,205
Surplus as regards policyholders
280,169,374
Total liabilities and capital and surplus
$ 807,693,196
I, John L. Sennott Jr., CEO and President of Capital Indemnity Corporation do hereby certify that to the best of my knowledge and belief, the foregoing is a full and true
statutory Statement of Admitted Assets and Liabilities, Capital and Surplus of the Operation at December 31, 2020, prepared in conformity with the accounting practices
prescribed by the Insurance Department of the State of Wisconsin. IN WITNESS WHEREOF, I have set my hand and affixed the seal of the Corporation at Middleton,
Wisconsin.
John L. Sennott Jr
CEO & President
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Capitol Indemnity Corporation
1600 Aspen Commons, Middleton, W153562
IMPORTANT NOTICE - TEXAS
To obtain information or make a complaint:
• You may contact your company representative at 1-800-475-4450
• You may call Capitol indemnity Corporation's toll -free telephone number for information or to
make a complaint at:
1-800-475-4450
• You may also write to Capitol Indemnity Corporation at:
Capitol Indemnity Corporation
1600 Aspen Commons
Middleton, Wisconsin 53562
• 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 78714-9104
FAX # (512) 490-1007
Web: htto://www.tdi.texas.aov
E-mail: ConsumerProtectionetdi.texas.aov
• PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about
a claim you should contact the agent or the company first. If the dispute is not resolved, you may
contact the Texas Department of Insurance.
• ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not
become a part or condition of the attached document.
SGE 020 (06-16) O 2016 CapSpecialty, Inc. All rights reserved. Page 1 of 1