HomeMy WebLinkAboutContract 56229-FP2-FP2City Secretary 56229 Contract No. _____ _
fORTWORTH® Date Received l/S/2025
1/13/2025
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: Crescent Cultural District Office
City Project No.: 103100
Improvement Type(s): Water� Sewer�
Original Contract Price: $238,352.00
Amount of Approved Change Order(s)
Revised Contract Amount:
Total Cost of Work Complete:
Contractor
Assistant Project Manager
Title
HC BECK, LTD
Company Name
Project Inspector
Pw6a9w�
Project Manager
Kand&!;Jan 8, 202514:05 CST)
CFA Manajl_er Je--%.:-. Lauren Prieur (Jan 8, 202514:52 CST)
TPW Director
Asst. City Manager
$238,352.00
Jan 8, 2025
Date
Jan 8, 2025
Date
Jan 8, 2025
Date
Jan 8, 2025
Date
Jan 8, 2025
Date
Jan 10, 2025
Date
Page 1 of 2
Notice of Project Completion
Project Name: Crescent Cultural District Office
City Project No.: 103100
City's Attachments
Final Pay Estimate 0
Change Order(s): ❑ Yes 0 N/A
Pipe Report: 0 Yes ❑ N/A
Contractor's Attachments
Affidavit of Bills Paid �
Consent of Surety �
Statement of Contract Time
Contract Time: 90 WD Days Charged: 423 WD
Work Start Date: 2/28/2022 Work Complete Date: 10/14/2024
Completed number of Soil Lab Test: 183
Completed number of Water Test: 15
Page 2 of 2
FORTWORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name CRESCENT CULTURAL DISTRICT OFFICE
Contract Limits
Project Type WATER IMPROVEMENTS
City Project Numbers 103100
DOE Number 3100
Estimate Number 1 Payment Number 1 For Period Ending 10/14/2024
WD
City Secretary Contract Number
Contract Date
Project Manager NA
Contractor HC BECK, LTD
1807 ROSS AVE, STE 500
DALLAS , TX 75201
Inspectors D. WATSON / C. HOLLINGSW
Contract Time 9AJD
Days Charged to Date 423
Contract is 100.00 Complete
Tuesday, December 10, 2024 Page 1 of 5
City Project Numbers 103100
Contract Name CRESCENT CUI; I'URAI, DIS'fRIC'I' OI�I�ICI:
Contract Limits
Project Type WATER IMPROVEMENTS
Project Funding
UNIT I: WATER IMPROVEMENTS
Item Description of Items �stimated Unit
No. Quaniry
l REMOVE 4" WATER LINE 315 LF
2 REMOVE 8" WATER LINE 45 LF
3 REMOVE 12" WATERLINE IS LF
4 4" - 12" PRESSURE PLUG 4 EA
5 REMOVE 8" WATER VALVE 1 EA
6 SALVAGE 1" WATERMETER 3 EA
7 SALVAGE 3" WATER METER 1 EA
8 SALVAGE 8" WATER METER 1 EA
9 REMOVE CONCRETE WATER VAULT 1 EA
10 TRENCH SAFETY 305 LF
11 DUCTILE IRON WATER FITTINGS W/ 2 TN
RESTRAINT
12 4" PVC WATER PIPE 50 LF
13 6" PVC WATER PIPE 95 LF
14 8" PVC WATER PII'E 16 LF
15 12" PVC WATER PIPE 290 LF
16 CONNECTION TO EXISTING 4" - 12" WATER 4 EA
MAIN
17 1" WATER SERVICE 1 EA
18 1" WATER SERVICE, METER RECONNECTION 1 EA
19 4" WATER METER & VAUL'f 1 EA
20 6" WATER METER & VAUL f 1 EA
21 4" GATE VALVE 1 EA
22 6" GATE VALVE 2 EA
23 8" GATE VALVE 2 EA
24 12" GATE VALVE 2 EA
25 12°X6" TAPPING SLEEVE & VALVF. 2 EA
26 REMOVE 3" WATER LINE 30 LF
Sub-Total of Previous Unit
DOE Number 3100
Estimate Number 1
Payment Number 1
For Period Ending 10/14/2024
Unit Cost Estimated
Total
$30.00 $9,450.00
$30.00 $1,350.00
$30.00 $450.00
$1,000.00 $4,000.00
$3,000.00 $3,000.00
$2,000.00 $6,000.00
$2,000.00 $2,000.00
$2,000.00 $2,000.00
$1,500.00 $1,500.00
$5.00 $1,525.00
$8,000.00 $16,000.00
$60.00 $3,000.00
$70.00 $6,650.00
$80.00 $1,280.00
$100.00 $29,000.00
$2,000.00 $8,000.00
$2,000.00 $2,000.00
$2,500.00 $2,500.00
$12,000.00 $12,000.00
$16,000.00 $16,000.00
$1,000.00 $1,000.00
$1,500.00 $3,000.00
$1,800.00 $3,600.00
$3,000.00 $6,000.00
$8,000.00 $16,000.00
$30.00 $900.00
$158,205.00
Completed Completed
Quaniry Total
315 $9,4�0.00
45 $1,3�0.00
IS $450.00
4 $4,000.00
1 $3,000.00
3 $6,000.00
1 $2,000.00
1 $2,000.00
1 $1,500.00
305 $1,525.00
2 $16,000.00
50 $3,000.00
95 $6,650.00
16 $1,280.00
290 $29,000.00
4 $8,000.00
1 $2,000.00
1 $2,500.00
1 $12,000.00
1 $16,000.00
1 $1,000.00
2 $3,000.00
2 $3,600.00
2 $6,000.00
2 $16,000.00
30 $900.00
$158,205.00
Tuesday, December 10, 2024 Page 2 of 5
City Project Numbers 103100
Contract Name CRESCENT CUI; I'URAI, DIS'fRIC'I' OI�I�ICI:
Contract Limits
Project Type SANITARY SEWER IMPROVEMENTS
Project Funding
UNIT II: SANTTARY SEWER IMPROVEMENTS
Item Description of Items �stimated Unit
No. Quaniry
l REMOVE 8" SEWER LINE 125 LF
2 REMOVE 4' SEWER MANHOLE 1 EA
3 POST CCTV INSPECTION 266 LF
4 MANHOLE VACUUM TESTING 3 EA
5 TRENCH SAFETY 266 LF
6 TRENCH WATER STOPS 4 EA
7 CONCRETE ENCASEMENT FOR UTILITY PIPES 18 CY
8 8" SEWER PIPE 16 LF
9 8" DIP SEWER PIPE 250 LF
10 EPDXY MANHOLE LINER 5 VF
11 4' MANHOLE 3 EA
Sub-Total of Previous Unit
DOE Number 3100
Estimate Number 1
Payment Number 1
For Period Ending 10/14/2024
Unit Cost Estimated Completed Completed
Total Quaniry Total
$30.00 $3,750.00 125 $3,7�0.00
$1,500.00 $1,500.00 1 $1,500.00
$12.00 $3,192.00 266 $3,192.00
$1,200.00 $3,600.00 3 $3,600.00
$5.00 $1,330.00 266 $1,330.00
$1,000.00 $4,000.00 4 $4,000.00
$225.00 $4,050.00 18 $4,050.00
$100.00 $1,600.00 16 $1,600.00
$I50.00 $37,500.00 250 $37,500.00
$325.00 $1,625.00 5 $1,625.00
$6,000.00 $18,000.00 3 $18,000.00
$80,147.00 $80,147.00
Tuesday, December 10, 2024 Page 3 of 5
City Project Numbers 103100
Contract Name CRESCENT CUI; I'URAI, DIS'fRIC'I' OI�I�ICI:
Contract Limits
Project Type SANITARY SEWER IMPROVEMENTS
Project Funding
Contract Information Summary
Original Contract Amount
Change Orders
Total Contract Price
DOE Number 3100
Estimate Number 1
Payment Number 1
For Period Ending 10/14/2024
$238,352.00
$238,352.00
Total Cost of Work Completed $238,352.00
Less % Retained $0.00
Net Earned $238,352.00
Earned This Period $238,352.00
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
$238,352.00
Tuesday, December 10, 2024 Page 4 of 5
City Project Numbers 103100
Contract Name CRESCENT CUI; I'URAI, DIS'fRIC'I' OI�I�ICI:
Contract Limits
Project Type SANITARY SEWER IMPROVEMENTS
DOE Number 3100
Estimate Number 1
Payment Number 1
For Period Ending 10/14/2024
Project Funding
Project Manager NA
Inspectors D. WATSON / C. HOLLINGSW
Contractor HC BECK, LTD
1807 ROSS AVE, STE 500
DALLAS , TX 75201
City Secretary Contract Number
Contract Date
Contract Time 90 WD
Days Charged to Date 423 WD
Contract is 000000 Complete
CITY OF FORT WORTH
SUMMARY OF CHARGES
Line Fund Account Center Amount Gross Retainage Net
Funded
Total Cost of Work Completed
Less % Retained
Net Earned
Earned This Period $238,352.00
Retainage This Period $0.00
Less Liquidated Damages
� Days @ $0.00 / Day
LessPavement Deficiency
Less Penalty
Less Previous Payment
Plus Material on Hand Less 15%
Balance Due This Payment
$238,352.00
$0.00
$238,352.00
$0.00
$0.00
$0.00
$0.00
$0.00
$238,352.00
Tuesday, December 10, 2024 Page 5 of 5
F�RTWORTH
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Crescent Cultural District Office
CITY PROJECT NUMBER: 103100
WATER
PIPE LAID SIZE TYPE
OPEN CUT 4" PVC
OPEN CUT 6" PVC
OPEN CUT 8" PVC
OPEN CUT 12" PVC
FIRE HYDRANTS: NONE
PIPE ABANDONED
DENSITIES:
NEW SERVICES:
SIZE
1"
PIPE
VALVES (16" OR LARGER)
TYPE OF PIPE
PASSED
COPPER
20
SEWER
PIPE LAID SIZE TYPE OF PIPE LF
OPEN CUT 8" PVC 16
OPEN CUT 8" DIP 250
PIPE ABANDONED
DENSITIES:
NEW SERVICES:
SIZE TYPE OF PIPE
PASSED
LF
50
95
16
290
NONE
LF
LF
TR�NSPORT:�TION 1�ND PUBLIC `��ORI�S
The City- of Fort ��'orth • 1000 Thxockmarton Stxeet • Fort ��'orth, T� 76012-6311
(817) 392 - 7941 • Fax: (817) 392 - 7845
F���������
TRANSPORTATION AND PUBLIC WORKS
October 28, 2024
HCBeck, Ltd.
810 Hemphill St.
Fort Worth TX, 78216
RE: Acceptance Letter
Project Name: Crescent Cultural District Office
Project Type: Water, Sewer, Paving, Drainage and Street Light
City Project No.: 103100
To Whom It May Concern:
On October 28, 2024 a final inspection was made on the subject project. There were no punch list items
identified at that time. The final inspection indicates that the work meets the City of Fort Worth
specifications and is therefore accepted by the City. The warranty period will start on October 28, 2024,
which is the date of the final inspection 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-
392-2481.
Sincerely,
Debbie Willhelm P.E., Project Manager
Cc: Curtis Hollingsworth, Inspector
Donald Watson, Inspection Supervisor
Aaron Ybarra, Senior Inspector
Andrew Goodman P.E., Program Manager
Dunaway, Consultant
Beck, Contractor
Crescent Real Estate Developers, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev.08/20/19
City Secretary
Contract No.
FQRT W� RT H Q Date Received
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: Crescent Cultural District Office
City Project No.: 103100
Improvement Type(s): Water 0 Sewer 0
Original Contract Price: $238,352.00
Amount of Approved Change Order(s)
Revised ContractAmount:
Total Cost of Work Complete: $238,352.00
Contractor
Title
HC BECK, LTD
Company Name
Project Inspector
Project Manager
CFA Manager
TPW Director
Asst. City Manager
Date
Date
Date
Date
Date
Date
Page 1 of 2
Notice of Project Completion
Project Name: Crescent Cultural District Office
City Project No.: 103100
City's Attachments
Final Pay Estimate 0
Change Order(s): ❑ Yes 0 N/A
Pipe Report: 0 Yes ❑ N/A
Contractor's Attachments
Affidavit of Bills Paid
Consent of Surety
Statement of Contract Time
Contract Time: 90 WD Days Charged: 423 WD
Work Start Date: 2/28/2022 Work Complete Date: 10/14/2024
Completed number of Soil Lab Test: 183
Completed number of Water Test: 15
Page 2 of 2
FORTWORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name CRESCENT CULTURAL DISTRICT OFFICE
Contract Limits
Project Type WATER IMPROVEMENTS
City Project Numbers 103100
DOE Number 3100
Estimate Number 1 Payment Number 1 For Period Ending 10/14/2024
WD
City Secretary Contract Number
Contract Date
Project Manager NA
Contractor HC BECK, LTD
1807 ROSS AVE, STE 500
DALLAS , TX 75201
Inspectors D. WATSON / C. HOLLINGSW
Contract Time 9AJD
Days Charged to Date 423
Contract is 100.00 Complete
Tuesday, December 10, 2024 Page 1 of 5
City Project Numbers 103100
Contract Name CRESCENT CUI; I'URAI, DIS'fRIC'I' OI�I�ICI:
Contract Limits
Project Type WATER IMPROVEMENTS
Project Funding
UNIT I: WATER IMPROVEMENTS
Item Description of Items �stimated Unit
No. Quaniry
l REMOVE 4" WATER LINE 315 LF
2 REMOVE 8" WATER LINE 45 LF
3 REMOVE 12" WATERLINE IS LF
4 4" - 12" PRESSURE PLUG 4 EA
5 REMOVE 8" WATER VALVE 1 EA
6 SALVAGE 1" WATERMETER 3 EA
7 SALVAGE 3" WATER METER 1 EA
8 SALVAGE 8" WATER METER 1 EA
9 REMOVE CONCRETE WATER VAULT 1 EA
10 TRENCH SAFETY 305 LF
11 DUCTILE IRON WATER FITTINGS W/ 2 TN
RESTRAINT
12 4" PVC WATER PIPE 50 LF
13 6" PVC WATER PIPE 95 LF
14 8" PVC WATER PII'E 16 LF
15 12" PVC WATER PIPE 290 LF
16 CONNECTION TO EXISTING 4" - 12" WATER 4 EA
MAIN
17 1" WATER SERVICE 1 EA
18 1" WATER SERVICE, METER RECONNECTION 1 EA
19 4" WATER METER & VAUL'f 1 EA
20 6" WATER METER & VAUL f 1 EA
21 4" GATE VALVE 1 EA
22 6" GATE VALVE 2 EA
23 8" GATE VALVE 2 EA
24 12" GATE VALVE 2 EA
25 12°X6" TAPPING SLEEVE & VALVF. 2 EA
26 REMOVE 3" WATER LINE 30 LF
Sub-Total of Previous Unit
DOE Number 3100
Estimate Number 1
Payment Number 1
For Period Ending 10/14/2024
Unit Cost Estimated
Total
$30.00 $9,450.00
$30.00 $1,350.00
$30.00 $450.00
$1,000.00 $4,000.00
$3,000.00 $3,000.00
$2,000.00 $6,000.00
$2,000.00 $2,000.00
$2,000.00 $2,000.00
$1,500.00 $1,500.00
$5.00 $1,525.00
$8,000.00 $16,000.00
$60.00 $3,000.00
$70.00 $6,650.00
$80.00 $1,280.00
$100.00 $29,000.00
$2,000.00 $8,000.00
$2,000.00 $2,000.00
$2,500.00 $2,500.00
$12,000.00 $12,000.00
$16,000.00 $16,000.00
$1,000.00 $1,000.00
$1,500.00 $3,000.00
$1,800.00 $3,600.00
$3,000.00 $6,000.00
$8,000.00 $16,000.00
$30.00 $900.00
$158,205.00
Completed Completed
Quaniry Total
315 $9,4�0.00
45 $1,3�0.00
IS $450.00
4 $4,000.00
1 $3,000.00
3 $6,000.00
1 $2,000.00
1 $2,000.00
1 $1,500.00
305 $1,525.00
2 $16,000.00
50 $3,000.00
95 $6,650.00
16 $1,280.00
290 $29,000.00
4 $8,000.00
1 $2,000.00
1 $2,500.00
1 $12,000.00
1 $16,000.00
1 $1,000.00
2 $3,000.00
2 $3,600.00
2 $6,000.00
2 $16,000.00
30 $900.00
$158,205.00
Tuesday, December 10, 2024 Page 2 of 5
City Project Numbers 103100
Contract Name CRESCENT CUI; I'URAI, DIS'fRIC'I' OI�I�ICI:
Contract Limits
Project Type SANITARY SEWER IMPROVEMENTS
Project Funding
UNIT II: SANTTARY SEWER IMPROVEMENTS
Item Description of Items �stimated Unit
No. Quaniry
l REMOVE 8" SEWER LINE 125 LF
2 REMOVE 4' SEWER MANHOLE 1 EA
3 POST CCTV INSPECTION 266 LF
4 MANHOLE VACUUM TESTING 3 EA
5 TRENCH SAFETY 266 LF
6 TRENCH WATER STOPS 4 EA
7 CONCRETE ENCASEMENT FOR UTILITY PIPES 18 CY
8 8" SEWER PIPE 16 LF
9 8" DIP SEWER PIPE 250 LF
10 EPDXY MANHOLE LINER 5 VF
11 4' MANHOLE 3 EA
Sub-Total of Previous Unit
DOE Number 3100
Estimate Number 1
Payment Number 1
For Period Ending 10/14/2024
Unit Cost Estimated Completed Completed
Total Quaniry Total
$30.00 $3,750.00 125 $3,7�0.00
$1,500.00 $1,500.00 1 $1,500.00
$12.00 $3,192.00 266 $3,192.00
$1,200.00 $3,600.00 3 $3,600.00
$5.00 $1,330.00 266 $1,330.00
$1,000.00 $4,000.00 4 $4,000.00
$225.00 $4,050.00 18 $4,050.00
$100.00 $1,600.00 16 $1,600.00
$I50.00 $37,500.00 250 $37,500.00
$325.00 $1,625.00 5 $1,625.00
$6,000.00 $18,000.00 3 $18,000.00
$80,147.00 $80,147.00
Tuesday, December 10, 2024 Page 3 of 5
City Project Numbers 103100
Contract Name CRESCENT CUI; I'URAI, DIS'fRIC'I' OI�I�ICI:
Contract Limits
Project Type SANITARY SEWER IMPROVEMENTS
Project Funding
Contract Information Summary
Original Contract Amount
Change Orders
Total Contract Price
DOE Number 3100
Estimate Number 1
Payment Number 1
For Period Ending 10/14/2024
$238,352.00
$238,352.00
Total Cost of Work Completed $238,352.00
Less % Retained $0.00
Net Earned $238,352.00
Earned This Period $238,352.00
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
$238,352.00
Tuesday, December 10, 2024 Page 4 of 5
City Project Numbers 103100
Contract Name CRESCENT CUI; I'URAI, DIS'fRIC'I' OI�I�ICI:
Contract Limits
Project Type SANITARY SEWER IMPROVEMENTS
DOE Number 3100
Estimate Number 1
Payment Number 1
For Period Ending 10/14/2024
Project Funding
Project Manager NA
Inspectors D. WATSON / C. HOLLINGSW
Contractor HC BECK, LTD
1807 ROSS AVE, STE 500
DALLAS , TX 75201
City Secretary Contract Number
Contract Date
Contract Time 90 WD
Days Charged to Date 423 WD
Contract is 000000 Complete
CITY OF FORT WORTH
SUMMARY OF CHARGES
Line Fund Account Center Amount Gross Retainage Net
Funded
Total Cost of Work Completed
Less % Retained
Net Earned
Earned This Period $238,352.00
Retainage This Period $0.00
Less Liquidated Damages
� Days @ $0.00 / Day
LessPavement Deficiency
Less Penalty
Less Previous Payment
Plus Material on Hand Less 15%
Balance Due This Payment
$238,352.00
$0.00
$238,352.00
$0.00
$0.00
$0.00
$0.00
$0.00
$238,352.00
Tuesday, December 10, 2024 Page 5 of 5
F�RTWORTH
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Crescent Cultural District Office
CITY PROJECT NUMBER: 103100
WATER
PIPE LAID SIZE TYPE
OPEN CUT 4" PVC
OPEN CUT 6" PVC
OPEN CUT 8" PVC
OPEN CUT 12" PVC
FIRE HYDRANTS: NONE
PIPE ABANDONED
DENSITIES:
NEW SERVICES:
SIZE
1"
PIPE
VALVES (16" OR LARGER)
TYPE OF PIPE
PASSED
COPPER
20
SEWER
PIPE LAID SIZE TYPE OF PIPE LF
OPEN CUT 8" PVC 16
OPEN CUT 8" DIP 250
PIPE ABANDONED
DENSITIES:
NEW SERVICES:
SIZE TYPE OF PIPE
PASSED
LF
50
95
16
290
NONE
LF
LF
TR�NSPORT:�TION 1�ND PUBLIC `��ORI�S
The City- of Fort ��'orth • 1000 Thxockmarton Stxeet • Fort ��'orth, T� 76012-6311
(817) 392 - 7941 • Fax: (817) 392 - 7845
F���������
TRANSPORTATION AND PUBLIC WORKS
October 28, 2024
HCBeck, Ltd.
810 Hemphill St.
Fort Worth TX, 78216
RE: Acceptance Letter
Project Name: Crescent Cultural District Office
Project Type: Water, Sewer, Paving, Drainage and Street Light
City Project No.: 103100
To Whom It May Concern:
On October 28, 2024 a final inspection was made on the subject project. There were no punch list items
identified at that time. The final inspection indicates that the work meets the City of Fort Worth
specifications and is therefore accepted by the City. The warranty period will start on October 28, 2024,
which is the date of the final inspection 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-
392-2481.
Sincerely,
T e66.� C�. G�/..��lia.�m
O
Debbie Willhelm P.E., Project Manager
Cc: Curtis Hollingsworth, Inspector
Donald Watson, Inspection Supervisor
Aaron Ybarra, Senior Inspector
Andrew Goodman P.E., Program Manager
Dunaway, Consultant
Beck, Contractor
Crescent Real Estate Developers, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev.08/20/19
STATE OF_Texas §
§
COUNTY OF_Tarrant §
BEFORE ME, a notary public in and for the State of Texas_, on this day personally appeared,
_Jeff Massie who, being by me duly sworn, on oath states:
l. My name is Jeff Massie . I am the Project Executive of HC Beck,
Ltd. ("Contractor") that performed work/supplied materials and/or equipment in connection with
the construction of Museum Place Office & Gara�e (the "Project"). The information provided
herein is true and correct and based upon my personal knowledge except as noted.
2. In consideration of the payment of $8,200.42 (the "Payment") to Contractor, Contractor
hereby fully and iinally releases, acquits, and forever discharges GPIF CD Office LLC ("Owner")
its lenders, partners, officers, sureties, insurers, reinsurers, directors, shareholders, employees,
agents, successors, landlord, and assigns (collectively, the "Released Parties"), of and from claims
and liens related to the Payment.
3. Contractor hereby certifies and warrants that all subcontractors, suppliers, laborers, and
lessors of construction equipment that have supplied labor, equipment, services, and/or materials
to Contractor in connection with the Project have been paid in full [except as follows]:
4. Contractor agrees to indemnify the Released Parties or any of them and hold them harmless
from any and all claims, costs (including attorneys' fees), liability, demands, and/or causes of
action which any of them may incur by virtue of Contractor's failure to pay any such
subcontractors, suppliers, laborers, and/or lessors.
5. This Affidavit is given to certify that all bills owed by Contractor have been paid. If
payment is made by check or draft, when the check or draft representing the Payment has been
properly endorsed and has been paid by the bank upon which it is drawn, this document will be
effective. If cash or certified funds are provided, this document will be immediately effective.
[INSERT NAME OF CONTRACTOR]
(Si a re)
Y�
Its:
SUBSCRIBED SWORN to before me by the said v Z� ��4- , this
�� day o 202`'�, to certify wh' h witness my hand and seal of office.
Notary Public in and for the S ate of
My Commission Expires: Z
{ � AMY BEARDEIN
Notary ID �t 1�399888.�
+ �" MY CommissJOn E�e�
F 09-2&2025
Maintenance Bond: No final consent of surety