HomeMy WebLinkAboutContract 59757-CA1a
CSC No. 59757-CAl
CITY OF FORT WORTH
ASSIGNMENT
For value received LBS Enterprise LLC ("Assignor"), hereby assigns to Perma-Patch,
LLC ("Assignee"), all of its right, title and interest in and to any and all sums of money now due
or to become due from the City of Fort Worth to Assignor under CSC4 59757 (the "Contracts")
and Assignee agrees to assume and perform all duties and obligations required by Assignor
under the terms of the Contracts.
This Assignment constitutes the entire agreement between Assignor and Assignee with
respect to the subject matter hereof. No modification of any provision of this Assignment shall
be effective unless in writing and sinned by Assignor and Assignee. This Assignment shall inure
to the benefit of and be binding upon Assignor and Assignee and their respective successors and
assigns. This Assignment shall be governed by the terms of the original Contracts between
Assignor and various other entities and the City of Fort Worth and the laws of the State of Texas,
without application of principles of conflicts of law.
This Assignment may be executed in one or more counterparts each of which shall be {
deemed an original but all of which together shall constitute one and the same instrument
Signed signature pages may be transmitted by facsimile or e-mail, and any such signature shall
have the same legal effect as an original.
Dated the l.L day ofe_kSe 2024,
Assgrunent
LBS Enterprise LLC
(Assignor)
$y:
Print: 7`•9��y �9 �efsavi
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Title: Chief Officer
Perma-Patch, LLC
(Assignee)
By:�-
Print.,
Mark DiBiao
Title:
VP of Finance
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Pagc 1 00
NOTARY ACKNOWLEDGEMENT
Oil the t..--3 day of A�av �,�e2 _ 2024, personally appeared
� C1biA,2�sa.? , acknowledged to cue that (s)he is the Chief Operating Officer of LBS
Enterprise LLC ("Assi nor"), and that (s)hc executed this document for the purposes and
consideration contained herein.
L me ise LLC
By:
Print_ y—X4ee-,r t,Rlelspn
Title: Chief Apeia Officer
SUBSCRIBED TO before me on this /5 day of Akvel&�� 2024,
c� s� AiVGELACLARiC WHITE No ry. iblic in and for the State of�
'^ NotarylD#t29420839
+� My Commission Expires My commission Expires:
Os June 17, 2025 -
NOTARY ACKNOWLEDGEMENT
On the day of. OovkmYJp. 2024, personally appeared Mark
DiBia6o, , who acknowledged to me that he is the Vice President of finance
of Perma-Patch, LLC ("Assignee'), and that he executed this document for the purposes and
consideration contained herein.
Perma-Patch, LLC,,,
By: ,
Print; Mark DiBiagi
Title. VP of Finance
SUBSCRIBED TO before me on this _Nk day of r t0%)tylt4" , 2024
GA
_ tjoTAR?
Assign ilcill
1)r\9. S jck
Notary Public in and for tlae State of
My commission Expires: 10`t1 —1
Page 2 oi' 3
._h.II��,.. -
CONSENT TO ASSIGNMENT
The City of Fort Worth consents to the assignment of LBS Enterprise LLC ("Assignor")
to Perma-Patch, LLC ("Assignee"), of all its rights, title, and obligation owing and all funds due
or to become due to Assignor under CSCO 59757 as long as all terms required of Assignor in
said contracts are met by Assignee.
CITY OF FORT WORTH
Nov 21, 2024
Lauren Prieur (Nov 21, 202411:07 CST)
Department Director
Date
op��
Nov 26, 2024
Assistant City Manager
Date
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ATTESTED BY:
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t eze.44p�d
Nov 26, 2024
n s a
uaan4
Jannette Goodall, City Secretary
Date
APPROVED AS TO FORM AND LEGALITY:
City of Fort Worth Assistant City Attorney
Contract Compliance Manager:
By signing I acknowledge that I am the person responsible
for the monitoring and administration of this contract, including ensuring all performance and
reporting requirements.
Z-a, eai[CL 7Deal".%,
Nov 21, 2024
Employee Signature/Date
Senior Administrative Assistant
Title
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Assignment Page 3 of
STATE OF MARYLAND
Department of Assessments and Taxation
I, DANIEL K. PHILLIPS OF THE STATE DEPARTMENT OF ASSESSMENTS AND TAXATION OF
THE STATE OF MARYLAND, DO HEREBY CERTIFY THAT THE DEPARTMENT, BY LAWS OF THE
STATE, IS THE CUSTODIAN OF THE RECORDS OF THIS STATE RELATING TO LIMITED
LIABILITY COMPANIES, OR THE RIGHTS OF LIMITED LIABILITY COMPANIES TO
TRANSACT BUSINESS IN THIS STATE, AND THAT I AM THE PROPER OFFICER TO EXECUTE
THIS CERTIFICATE.
I FURTHER CERTIFY THAT PERMA-PATCH, LLC (Z18225565) , REGISTERED AUGUST 24,
2017, IS A LIMITED LIABILITY COMPANY EXISTING UNDER AND BY VIRTUE OF THE LAWS
OF THE STATE OF DELAWARE, AND THAT THE LIMITED LIABILITY COMPANY IS AT THE
TIME OF THIS CERTIFICATE IN GOOD STANDING TO TRANSACT BUSINESS.
IN WITNESS WHEREOF, I HAVE HEREUNTO SUBSCRIBED MY SIGNATURE AND AFFIXED THE
SEAL OF THE STATE DEPARTMENT OF ASSESSMENTS AND TAXATION OF MARYLAND AT
BALTIMORE ON THIS NOVEMBER 06, 2024.
t�IVIAI(-
Daniel K. Phillips
Director
700 East Pratt Street, 2nd Flr, Ste 2700, Baltimore, Maryland 21202
Telephone Baltimore Metro (410) 767-1344 / Outside Baltimore Metro (888) 246-5941
MRS (Maryland Relay Service) (800) 735-2258 TT/Voice
Online Certificate Authentication Code: 0_I-oteNkyVCIg164j9Zw
To verify the Authentication Code, visit http://dat.maryland.gov/verify
Form W-9 Request for Taxpayer Give Form to the
(Rev. October2018) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service ► Go to www.irs.gov1FormW9 for instructions and the latest information-
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Perma-Patch, LLC
2 Business nameldisrogarded entity name, if different from above
CIS
(1)
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
4 Exemptions (codes apply only to
to
following seven boxes.
certain entities, not individuals; see
a
o
❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
instructions on page 3):
H
QC
single -member LLC
Exempt payee code (if any)
41 v
0 Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► P
p 3
Note; Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
Exemption from FATCA reporting
e
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is disregarded from for federal
code fit any)
a
not the owner U.S, tax purposes. Otherwise, a single -member LLC that
w
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
avi
❑ Other (see instructions) ►
(ppfiesmaccountsnmintmdOut&&deu.S)
N
5 Address (number, street, and apt. or suite no.) See instructions. I Requester's name and address (optional)
6
6123 Oakleaf Avenue
JI
6 City, state, and ZIP code
Baltimore, MD 21215
7 List account number(s) here (optional)
ILM Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a W m
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (ElN). If you do not have a number, see How to get a d I
TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
8 fl2 -I 2 11 5 13 9 0 5
Certification -
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign I Signature of
Here U.S. person 0-
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.govIFormIN9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), 'individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
date ► f l a i l �(Ja�,.
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1 D99-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a 71N, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
PERMA-PAT(H,
PERMANENT PAVEMENT
REPAIR
6123 Oakleaf Avenue, Baltimore, MD 21215
November 6, 2024
To: Tracy Walter, City of Fort Worth
From: Jon Bigden, Executive Vice President
Subject: Perma-Patch LLC Acquisition of LBS Enterprise
Dear Ms. Walter,
This letter is to advise you of the acquisition of LBS Enterprises by Perma-Patch LLC, Effective September 17,
2024.
With this acquisition, FORT WORTH CITY SECRETARY CONTRACT NO. 59757 will now be serviced by Perma-
Patch LLC. Orders can be placed to Perma-Patch LLC by emailing ordersCcDoermaoatch.com or by calling 800-847-
5744. My contact detail are below. We also have a Texas contact: Glenn Stewart 214-704-4708.
If it possible to expedite this transfer, that would be very helpful. Mr. Cornelius White at the City of Fort Worth
seeks to place an order tto us for products he needs under Contract No. 59757.
Please feel free to reach out to me or to Glenn with any questions.
Respectfully,
Jon Bigden
Executive Vice President
Perma-Patch, LLC
(m) 443-621-7245
(o) 800-547-5744
ibisden(@i3ermapatch.com