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Contract - Chasco Constructors - 5/10/2018 City of Round Rock, Texas Contract Forms Standard Form of Agreement: Section 00500 City of Round Rock, Texas Standard Form of Agreement between Owner and Contractor AGREEMENT made as of the411610(6424k(14)day of 114 4.y in the year 20 10. BETWEEN the Owner: City of Round Rock,Texas(hereafter"Owner"or"City") 221 East Main Street Round Rock,Texas 78664 and the Contractor Chasco Constructors ("Contractor") The Project is described as: Dry Branch Tributaries Channel Improvements The Engineer is: City of Round Rock For and in consideration of the mutual terms, conditions and covenants of this Agreement and all accompanying documents between Owner and Contractor, the receipt and sufficiency of which are hereby acknowledged,Owner and Contractor agree as follows: ARTICLE I THE CONTRACT DOCUMENTS The Contract Documents consist of this Agreement,Conditions of the Contract(General,Supplementary and other Conditions),Drawings, Specifications,Addenda issued prior to execution of this Agreement, other documents listed in this Agreement and Modifications issued after execution of this Agreement;these form the Contract,and are as fully a part of the Contract as if attached to this Agreement or repeated herein.The Contract represents the entire and integrated agreement between the parties hereto and supersedes prior negotiations,representations or agreements, either written or oral.An enumeration of the Contract Documents,other than Modifications,appears in Article 7. ARTICLE 2 THE WORK OF THIS CONTRACT Contractor shall fully execute the Work described in the Contract Documents,except to the extent specifically indicated in the Contract Documents to be the responsibility of others. 00500 4-2016 Page 1 of 5 Standard Form of Agreement 00307791 law20b l M'a24 ARTICLE 3 DATE OF COMMENCEMENT;DATE OF SUBSTANTIAL COMPLETION;DATE OF FINAL COMPLETION 3.1 The date of commencement of the Work shall be the date of this Agreement unless a different date is stated below or provision is made for the date to be fixed in a Notice to Proceed issued by Owner. 3.2 The Contract Time shall be measured from the date delineated in the Notice to Proceed. 3.3 Contractor shall commence Work within seven ( 7 ) calendar days from the date delineated in the Notice to Proceed. 3.4 Contractor shall achieve Substantial Completion of the items of Work listed on Attachment A to this Agreement no later than N/A ( N/A )calendar days from issuance by Owner of Notice to Proceed, and Contractor shall achieve Substantial Completion of the entire Work no later than two-hundred ten ( 210 )calendar days from issuance by Owner of Notice to Proceed,subject to adjustments of this Contract Time as provided in the Contract Documents. 3.5 If Contractor fails to achieve Substantial Completion of the Work(or any portion thereof)on or before the date(s)specified for Substantial Completion in the Agreement,Contractor shall pay to Owner,as liquidated damages, the sum of five-hundred and No/100 Dollars($ 500.00 ) for each calendar day that Substantial Completion is delayed after the date(s) specified for Substantial Completion. It is hereby agreed that the liquidated damages to which Owner is entitled hereunder are a reasonable forecast of just compensation for the harm that would be caused by Contractor's failure to achieve Substantial Completion of the Work(or any portion thereof)on or before the date(s)specified for Substantial Completion in the Agreement.It is agreed that the harm that would be caused by such failure,which includes loss of expected use of the Project areas,provision of alternative storage facilities and rescheduling of moving and occupancy dates,is one that is incapable or very difficult of accurate estimation.It is hereby agreed that if Substantial Completion of the Work (or any portion thereof) is not achieved on or before thirty (30) days after the date(s) specified for Substantial Completion in the Agreement,the Owner shall have the option to either collect liquidated damages as set forth herein or to thereafter rely on its remedies under the Contract Documents and at law and in equity, including without limitation,the recovery of actual damages.The date(s)specified for Substantial Completion of the Work(or any portion thereof)in the Agreement shall be subject to adjustment as provided in the Contract Documents. 3.6 Contractor shall achieve Final Completion of the entire Work no later than two-hundred fourty ( 240 )calendar days from issuance by Owner of Notice to Proceed. ARTICLE 4 CONTRACT SUM 4.1 Owner shall pay Contractor the Contract Sum in current funds for Contractor's performance of the Contract. The Contract Sum shall be one-million three-hundred twenty-eight thousand and fifty-two ($ 1,328,052.00 ),subject to additions and deductions as provided in the Contract Documents. 4.2 Does the Contract Sum include alternates which are described in the Bid Form? No . Yes X .If yes,please provide details below: Add Alternate#1 & Add Alternate#2 00500 4-2016 Page 2 of 5 Standard Form of Agreement 00307791 ARTICLE 5 PAYMENTS 5.1 PROGRESS PAYMENTS 5.1.1 Based upon Applications for Payment submitted to Engineer and Owner by Contractor,and Certificates for Payment issued by Engineer and not disputed by Owner and/or Owner's lender,Owner shall make progress payments on account of the Contract Sum to Contractor as provided below, in Article 14 of the City of Round Rock General Conditions,and elsewhere in the Contract Documents. 5.1.2 The period covered by each Application for Payment shall be one calendar month ending on the last day of the month. 5.1.3 Provided that an Application for Payment is received by Engineer and Owner, and Engineer issues a Certificate of Payment not later than the tenth(10th) day of a month, Owner shall make payment to Contractor not later than the tenth(10th)day of the next month.If an Application for Payment is received by Engineer and Owner after the application date fixed above,payment shall be made by Owner not later than one month after the Engineer issues a Certificate for Payment. 5.1.4 Each Application for Payment shall be based on the most recent schedule of values submitted by Contractor in accordance with the Contract Documents.The schedule of values shall allocate the entire Contract Sum among the various portions of the Work. The schedule of values shall be prepared in such form and supported by such data to substantiate its accuracy as Engineer and Owner may require.This schedule,unless objected to by Engineer or Owner, shall be used as a basis for reviewing Contractor's Applications for Payment. 5.1.5 Applications for Payment shall warrant the percentage of completion of each portion of the Work as of the end of the period covered by the Application for Payment. 5.1.6 Subject to other provisions of the Contract Documents, the amount of each progress payment shall be computed as provided in Article 14 of the City of Round Rock General Conditions. 5.1.7 Except with Owner's prior written approval, Contractor shall not make advance payments to suppliers for materials or equipment which have not been delivered and stored at the site. 5.2 FINAL PAYMENT 5.2.1 Final payment, constituting the entire unpaid balance of the Contract Sum, shall be made by Owner to Contractor when: .1 Contractor has fully performed the Contract except for Contractor's responsibility to correct Work, and to satisfy other requirements,if any,which extend beyond final payment;and .2 a final Certificate for Payment has been issued by Engineer. 5.2.2 Owner's final payment to Contractor shall be made no later than thirty (30) days after the issuance of Engineer's final Certificate for Payment. In no event shall final payment be required to be made prior to thirty(30) days after all Work on the Contract has been fully performed.Defects in the Work discovered prior to final payment shall be treated as non-conforming Work and shall be corrected by Contractor prior to final payment,and shall not be treated as warranty items. ARTICLE 6 TERMINATION OR SUSPENSION 6.1 The Contract may be terminated by Owner or Contractor as provided in Article 15 of the City of Round Rock General Conditions. 00500 4-2016 Page 3 of 5 Standard Form of Agreement 00307791 6.2 The Work may be suspended by Owner as provided in Article 15 of the City of Round Rock General Conditions. ARTICLE 7 ENUMERATION OF CONTRACT DOCUMENTS 7.1 The Contract Documents,except for Modifications issued after execution of this Agreement,are enumerated as follows: 7.1.1 The Agreement is this executed version of the City of Round Rock, Texas Standard Form of Agreement between Owner and Contractor,as modified. 7.1.2 The General Conditions are the "City of Round Rock Contract Forms 00700," General Conditions, as modified. 7.1.3 The Supplementary, Special,and other Conditions of the Contract are those contained in the Project Manual dated March 2018 7.1.4 The Specifications are those contained in the Project Manual dated March 2018 7.1.5 The Drawings,if any,are those contained in the Project Manual dated March 2018 7.1.6 The Insurance&Construction Bond Forms of the Contract are those contained in the Project Manual dated March 2018 7.1.7 The Notice to Bidders,Instructions to Bidders,Bid Form,and Addenda,if any,are those contained in the Project Manual dated March 2018 7.1.8 If this Agreement covers construction involving federal funds, thereby requiring inclusion of mandated contract clauses, such federally required clauses are those contained in the "City of Round Rock Contract Forms 03000,"Federally Required Contract Clauses,as modified. 7.1.9 Other documents,if any,forming part of the Contract Documents are as follows: N/A ARTICLE 8 MISCELLANEOUS PROVISIONS 8.1 Where reference is made in this Agreement to a provision of any document, the reference refers to that provision as amended or supplemented by other provisions of the Contract Documents. 8.2 Owner's representative is: Federico Sanchez,P.E.,Stormwater Engineer 2008 Enterprise Drive Round Rock,Texas 78664 fsanchez crroundrocktexas.gov;(512)218-6609 8.3 Contractor's representative is: Bill Bambrick,Project Manager 2801 E Old Settlers Blvd Round Rock,TX 78665 bill a chasco.com;(512)848-3327 8.4 Neither Owner's nor Contractor's representative shall be changed without ten(10)days'written notice to the other party. 8.5 Waiver of any breach of this Agreement shall not constitute waiver of any subsequent breach. 00500 4-2016 Page 4 of 5 Standard Form of Agreement 00307791 8.6 Owner agrees to pay Contractor from available funds for satisfactory performance of this Agreement in accordance with the bid or proposal submitted therefor,subject to proper additions and deductions,all as provided in the General Conditions, Supplemental Conditions, and Special Conditions of this Agreement, and Owner agrees to make payments on account thereof as provided therein. Lack of funds shall render this Agreement null and void to the extent funds are not available. This Agreement is a commitment of City of Round Rock's current revenues only. 8.7 Although this Agreement is drawn by Owner,both parties hereto expressly agree and assert that,in the event of any dispute over its meaning or application,this Agreement shall be interpreted reasonably and fairly,and neither more strongly for nor against either party. 8.8 This Agreement shall be enforceable in Round Rock,Texas, and if legal action is necessary by either party with respect to the enforcement of any or all of the terms or conditions herein, exclusive venue for same shall lie in Williamson County, Texas. This Agreement shall be governed by and construed in accordance with the laws and court decisions of the State of Texas. 8.9 Both parties hereby expressly agree that no claims or disputes between the parties arising out of or relating to this Agreement or a breach thereof shall be decided by an arbitration proceeding,including without limitation,any proceeding under the Federal Arbitration Act(9 USC Section 1-14)or any applicable state arbitration statute. 8.10 The parties, by execution of this Agreement, bind themselves, their heirs, successors, assigns, and legal representatives for the full and faithful performance of the terms and provisions hereof. This Agreement is entered into as of the day and year first written above and is executed in at least three(3) original copies, of which one is to be delivered to Contractor, one to Engineer for use in the administration of the Contract,and the remainder to Owner. OWNER CONTRACTOR CITY OF 'OUND ' I K, XASi, CG\W S CO e • Printed Name: Vti/4 A AB A Printed Name: CAW�I ci(e,L ). ;Y(. I Title Title: TO,5 j(1-e,n+- Date Signed: 9 •14-• 19) Date Signed: MCA I 14+ 2(� 1 6 ATTEST: 4511114,— 1A1Vials' City Clerk FOR! IT ,APP OVED.• S TO FORM: 4100r.401 A., At orney 00500 4-2016 Page 5 of 5 Standard Form of Agreement 00307791 PERFORMANCE BOND Bond# 58S211346 THE STATE OF TEXAS § § KNOW ALL BY THESE PRESENTS: COUNTY OF WILLIAMSON § That Chasco Constructors of the City of Round Rock , County of Williamson , and State of Texas , as Principal, and Liberty Mutual Insurance Company authorized under the law of the State of Texas to act as surety on bonds for principals, are held and firmly bound unto THE CITY OF ROUND ROCK,TEXAS, (Owner),in the penal sum of One Million Three Hundred Twenty-Eight Thousand Fifty-Two Dollars &no/100 Dollars ($ 1,328,052.00 ) for the payment whereof, well and truly to be made the said Principal and Surety bind themselves, and their heirs, administrators, executors, successors and assigns,jointly and severally,by these presents: WHEREAS, the P.rncipal has entered into certain written Agreement with the Owner dated the 2-4 day of , 20j to which the Agreement is hereby referred to and made a part hereof as lly and to the same extent as if copied at length herein consisting of: Dry Branch Tributaries Channel Improvements (Name of the Project) NOW, THEREFORE, THE CONDITIONS OF THIS OBLIGATION IS SUCH, that if the said Principal shall faithfully perform said Agreement and shall, in all respects, duly and faithfully observe and perform all and singular the covenants, conditions and agreements in and by said Agreement, agreed and covenanted by the Principal to be observed and performed, including but not limited to, the repair of any and all defects in said work occasioned by and resulting from defects in materials furnished by or workmanship of, the Principal in performing the Work covered by said Agreement and occurring within a period of twelve (12)months from the date of Final Completion and all other covenants and conditions, according to the true intent and meaning of said Agreement and the Plans and Specifications hereto annexed, then this obligation shall be void; otherwise to remain in full force and effect; PROVIDED, HOWEVER, that this bond is executed pursuant to the provisions of Chapter 2253, Texas Government code, as amended, and all liabilities on this bond shall be determined in accordance with the provisions of said Chapter 2253 to the same extent as if it were copied at length herein. Page 1 00610 7-2009 Performance Bond 00090656 PERFORMANCE BOND (continued) Surety, for value received, stipulates and agrees that no change, extension of time, alteration or addition to the term of the Agreement, or to the Work performed thereunder, or the Plans, Specifications, or drawings accompanying the same, shall in anywise affect its obligation on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the Agreement, or to the work to be performed thereunder. IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this instrument this 11th day of May , 2018 . Chasco Constructors Liberty Mutual Insurance Company Principal Surety r (\s S A , (m\o c' :7( . Robert James Nitsche Printed Name Printed Na e By: �� �'i .--- By: ,e2iaterA/A, Title: -pce S deir\-}- Title: Attorney j -Fact Address: 2801 E. Old Settlers Blvd Address: 143 E.Austin Round Rock, TX 78665 Giddings, TX 78942 Residt Agent of urety: ,rii f 4/1.‘ -' A6,1/ ' //on Signature Robert James Nitsche Printed Name 143 E. Austin Street Address Giddings, TX 78942 City, State & Zip Code Page 2 00610 7-2009 Performance Bond 00090656 PAYMENT BOND Bond# 58S211346 THE STATE OF TEXAS § § KNOW ALL MEN BY THESE PRESENTS: COUNTY OF WILLIAMSON § That Chasco Constructors , of the City of Round rock , County of Williamson , and State of Texas as Principal, andiberty Mutual InsuranceCompany authorized under the laws of the State of Texas to act as Surety on Bonds for Principals, are held and firmly bound unto THE CITY OF ROUND ROCK, (OWNER), and all subcontractors, workers, laborers, mechanics and suppliers as their interest may appear, all of whom shall have the right to sue upon this bond, in the penal sum of One Million Three Hundred Twenty-Eight Thousand Fifty-Two Dollar&no/100-- Dollars ($ 1,328,052.00 ) for the payment whereof, well and truly be made the said Principal and Surety bind themselves and their heirs, administrators, executors, successors, and assigns,jointly and severally,by these presents: WHEREAS, the Principal has entered into a certain written Agreement with the Owner, dated the '1K- day of 4 , 20 g) , to which Agreement is hereby referred to and made a part hereof as fu y and to the same extent as if copied at length herein consisting of: Dry Branch Tributaries Channel Improvements (Name of the Project) NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if the said Principal shall well and truly pay all subcontractors, workers, laborers, mechanics, and suppliers, all monies to them owing by said Principals for subcontracts, work, labor, equipment, supplies and materials done and furnished for the construction of the improvements of said Agreement, then this obligation shall be and become null and void; otherwise to remain in full force and effect. PROVIDED, HOWEVER, that this bond is executed pursuant to the provisions of Chapter 2253, Texas Government code, as amended, and all liabilities on this bond shall be determined in accordance with the provisions of said Chapter 2253 to the same extent as if it were copied at length herein. Page 1 00620 7-2009 Payment Bond 00090656 PAYMENT BOND (continued) Surety, for value received, stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Agreement, or to the Work performed thereunder, or the plans, specifications or drawings accompanying the same shall in anywise affect it's obligation on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the contract, or to the work to be performed thereunder. IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this Instrument this 11th day of May , 2018 . Chasco Constructors Liberty Mutual Insurance Company Principal Surety (\k10442 j (- \cA(Q C. Robert James Nitsche Printed Name Printed N dx; By� ' B �� C � 174j710' A By: Title: ` cep ,�;.p,� Title: Attorney -Fact Address: 2801 E. Old Settlers Blvd Address: 143 E. Austin Round Rock, TX 78665 Giddings, TX 78942 Resi t Agent Surety: /41/ Signature Robert James Nitsche Printed Name 143 E. Austin Street Address Giddings, TX 78942 Page 2 00620 7-2009 Payment Bond 00090656 THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND. This Power of Attorney limits the acts of those named herein,and they have no authority to bind the Company except in the manner and to the extent herein stated. • Certificate No. 7886125 Liberty Mutual Insurance Company The Ohio Casualty Insurance Company West American Insurance Company POWER OF ATTORNEY KNOWN ALL PERSONS BY THESE PRESENTS:That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire,that Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts, and West American Insurance Company is a corporation duly organized under the laws of the State of Indiana(herein collectively called the"Companies"),pursuant to and by authority herein set forth,does hereby name,constitute and appoint, Craig Parker;David Ferguson;Kenneth Nitsche;Nina Smith; Robert James Nitsche; Robert K.Nitsche;Violet Frosch all of the city of Giddings ,state of TX each individually if there be more than one named,its true and lawful attorney-in-fact to make,execute,seal,acknowledge and deliver,for and on its behalf as surety and as its act and deed,any and all undertakings,bonds,recognizances and other surety obligations,in pursuance of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons. IN WITNESS WHEREOF,this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed thereto this 7th day of September , 2017 . 5, Cs ,0.1 I Ns ox,:. `„, u•,S U,,,. ,x,11 t'��u Uvt ,Y��� �,.,.•,c,F�)� ?, f• , ',,, The Ohio Casualty Insurance Company N Liberty Mutual Insurance Company as o 1919 h ' 1912 - f 1991 m C k West American Insurance Company '^ • V C ' % = * it * ��.yu> '1 C STATE OF PENNSYLVANIA ss David M.Carey Assistant Secretary C u- COUNTY OF MONTGOMERY C N01 On this 7th day of September , 2017,before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance v F- v of Company, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do,execute the foregoing instrument for the purposes 7,(n p 2 therein contained by signing on behalf of the corporations by himself as a duly authorized officer. �)W e > IN WITNESS WHEREOF,I have hereunto subscribed my name and affixed my notarial seal at King of Prussia,Pennsylvania,on the day and year first above written. 8 Q. P PAS?. COMMONWEALTH OF PENNSYLVANIA O -T3g(47S.ctis •9(f { Notarial Seal d: .N ' Teresa Pastella,Notary Public. By: ateli 0 cts a) OF Upper Merlon Twp.,Montgomery County Teresa Pastella,Notary Public L — L �$' My Commission Expires March 28,2.021 c y to R3 aj Q 2 ivsvcvP E �.+ rAI Y Pkg,4.* Member.Pennsylvania Association of Notaries a A+.1 as C (13 This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual ,t/N O nj Insurance Company,and West American Insurance Company which resolutions are now in full force and effect reading as follows: _c O C)(1) a) tC i ARTICLE IV-OFFICERS-Section 12.Power of Attorney,Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President,and subject 0 C .9 49, to such limitation as the Chairman or the President may prescribe,shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Corporation to make,execute,seal, ,�y O,= acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety obligations. Such attorneys-in-fact,subject to the limitations set forth in their respective -5 2 E ai powers of attorney,shall have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so '7 a) a executed,such instruments shall be as binding as if signed by the President and attested to by the Secretary.Any power or authority granted to any representative or attorney-in-fact under >.Q ”' `' the provisions of this article may be revoked at any time by the Board,the Chairman,the President or by the officer or officers granting such power or authority. "- V �N •( C ARTICLE XIII-Execution of Contracts-SECTION 5.Surety Bonds and Undertakings.Any officer of the Company authorized for that purpose in writing by the chairman or the president, E 0? > E and subject to such limitations as the chairman or the president may prescribe,shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Company to make,execute, s-M O 16 seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety obligations. Such attorneys-in-fact subject to the limitations set forth in their C o0 Z 0 respective powers of attorney,shall have full power to bind the Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so v o executed such instruments shall be as binding as if signed by the president and attested by the secretary. H 0 Certificate of Designation-The President of the Company,acting pursuant to the Bylaws of the Company,authorizes David M.Carey,Assistant Secretary to appoint such attorneys-in- fact as may be necessary to act on behalf of the Company to make,execute,seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety obligations. Authorization-By unanimous consent of the Company's Board of Directors,the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the Company,wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds,shall be valid and binding upon the Company with the same force and effect as though manually affixed. I, Renee C. Llewellyn, the undersigned, Assistant Secretary, The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company do hereby certify that the original power of attorney of which the foregoing is a full,true and correct copy of the Power of Attorney executed by said Companies, is in full force and effect and has not been revoked. IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this 11th day of May ,20 18 . a Y nki.s N S uR �~ at bii4�:'gam ^�tp+lril 4 ,� ,,(t , :: o 119 3 n 1912 1991 7 By: y '.:� o a , Renee C.Llew ssistant Secretary v',y."`r,:at,>? ; - /T .:r`t'rf'>v` �'' ',LOU, '. 384 of 500 LMS_12873_022017 Client#: 10288 CHASCCON1 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/11/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT The Nitsche Group PHONE Joyce Hinze FAX 143 East Austin (Pk?No,Ext):979-540-2240 (A/c,No): Giddings,TX 78942-3299 ADDREss: Joyceh@thenitschegroup.com INSURER(S)AFFORDING COVERAGE NAIC# 979 542-3666 INSURER A:Liberty Insurance Corporation 42404 INSURED INSURER B:Liberty Mutual Fire Insurance Company 23035 Chasco Constructors, LTD., LLP INSURER C P.O. Box 1057 Round Rock,TX 78680 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBERLIMITS (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY TB7Z91463740028 03/09/2018 03/09/2019 EACH OCCURRENCEEE $1,000,000 CLAIMS-MADE X OCCUR PREMISESO(Ea occur ence) $100,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECOT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY AS2Z91463740018 03/09/2018 03/09/2019 E aocideDj INGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) $ A X UMBRELLA LIAB X OCCUR TH7Z91463740048 03/09/2018 03/09/2019 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$10000 $ B WORKERS COMPENSATION WC2Z91463740038 03/09/2018 03/09/2019 X STATUTF FOTH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Job: Dry Branch Tributaries Channel Improvements As per policy provision, Certificate Holder is listed as additional insured in regard to the auto and general liability policies as provided by blanket additional insured endorsement when required by written contract. A blanket waiver of subrogation endorsement is provided to the Certificate Holder in regard to the auto, general liability and workers compensation policies as per policy provision when required by (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION City of Round Rock SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Manager ACCORDANCE WITH THE POLICY PROVISIONS. 221 E. Main St. Round Rock,TX 78664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03)___ 1 of 2 The ACORD name and logo are registered marks of ACORD THE CITY OF ROUND ROCK BIDS EXTENDED AND CHECKED `1457" Utilities& Environmental Services 2008 Enterprise Drive BY: Jorae R& DLH Round Rods, Texas 78664 DATE: 4/10/2018 BID TABULATION SHEET: 1 of 4 CONTRACT : Dry Branch Tributaries Channel Im rovements Smith Contracting ChascoConstructors ERS of MS 9 Austin Filter Systems LOCATION : 2008 Enterprise Drive Statement of Safety?Yes Statement of Safety?Yes Statement of Safety?Yes Statement of Safety?Yes DATE:4/10/2018 Addenda?Yes Addenda?Yes Addenda?Yes Addenda?Yes TIME:2:00 m Bid Bond?Yes Bid Bond?Yes Bid Bond?Yes Bid Bond?Yes BASE BI D APPROX. UNIT UNIT UNIT UNIT ITEM 4 ITEM DESCRIPTION QTY. UNIT PRI CE COST PRICE COST PRI CE COST PRICE COST 1 Preparing Right of Way 7 AC $15,000.00 $105,000.00 $25,000.00 $175,000.00 $17,000.00 $119,000.00 $10,000.00 $70,000.00 2 Channel Excavation 15300 CY $20.00 $306,000.00 $20.00 $306,000.00 $13.00 $198,900.00 $12.00 $183,600.00 3 Embankment 5490 CY $8.00 $43,920.00 $10.00 $54,900.00 $6.45 $35,410.50 $15.00 $82,350.00 4 Conc.Structures(24' RCP Headwal l) 3 CY $550.00 $1,650.00 $1,000.00 $3,000.00 $2,300.00 $6,900.00 $700.00 $2,100.00 5 Conc.Structures(42" RCP Headwall) 3 CY $1,500.00 $4,500.00 $1,500.00 $4,500.00 JL500.00 $4,500.00 $700.00 $2,100.00 6 Conc.Structures(12" PVCHeadwal1) 0.5 CY $1,800.00 $900.00 $1,000.00 $500.00 $3,800.00 $1,900.00 $800.00 $400.00 7 Concrete For Structures(Apron Slabs) 250 SY $79.00 $19,750.00 $105.00 $26,250.00 $124.00 $31,000.00 $150.00 $37,500.00 8 Conc.Structures(Drop Structure) 1 CY $2,000.00 $2,000.00 $1,000.00 $1,000.00 $3,600.00 $3,600.00 $1,500.00 $1,500.00 9 Conc.Structures(Trench Drain) 1 EA $13,000.00 $13,000.00 $16,750.00 $16,750.00 $8,600.00 $8,600.00 $6,000.00 $6,000.00 10 ManholeAdjustments 4 EA $1,300.00 $5,200.00 $1,500.00 $6,000.00 $1,500.00 $6,000.00 $1,500.00 $6,000.00 11 New Manhole Construction,60" DIA 1 EA $6,000.00 $6,000.00 $6,000.00 $6,000.00 $7,000.00 $7,000.00 $8,000.00 $8,000.00 12 NEvv M anhol e Constructi on,48" DIA 1 EA $5,000.00 $5,000.00 $6,570.00 $6,570.00 $6,200.00 $6,200.00 $6,000.00 $6,000.00 13 Ripe,24" RCP 75 LF $77.00 $5,775.00 $100.00 $7,500.00 $157.00 $11,775.00 $225.00 $16,875.00 14 R pe,42" RCP(Reuse Exi sti ng Ri pe) 150 LF $140.00 $21,000.00 $175.00 $26,250.00 $228.00 $34,200.00 $375.00 $56,250.00 15 Pipe, 12" DIA Steel Casing 60 LF $75.00 $4,500.00 $90.00 $5,400.00 $148.00 $8,880.00 $200.00 $12,000.00 16 Pipe,6" DIA SDR-26 PVC 220 LF $42.00 $9,240.00 $55.00 $12,100.00 $55.00 $12,100.00 $120.00 $26,400.00 17 Ripe, 12" DIA SDR-26 PVC 442 LF $65.00 $28,730.00 $55.00 $24,310.00 $58.00 $25,636.00 $100.00 $44,200.00 18 Pipe, 18" DIA Steel Casing 125 LF $80.00 $10,000.00 $115.00 $14,375.00 $141.00 $17,625.00 $200.00 $25,000.00 19 Dry Rods Riprap 240 SY $63.00 $15,120.00 $130.00 $31,200.00 $47.00 $11,280.00 $50.00 $12,000.00 20 Dry Rods Riprap(New Tri dcleChannel) 729 SY $35.00 $25,515.00 $45.00 $32,805.00 $42.00 $30,618.00 $40.00 $29,160.00 21 Gabion Baskets 359 CY $260.00 $93,340.00 $230.00 $82,570.00 $253.00 $90,827.00 $500.00 $179,500.00 22 Soil Retention Blanket 17260 SY $1.50 $25,890.00 $1.50 $25,890.00 $2.43 $41,941.80 $2.50 $43,150.00 23 Topsoil & Seedbed Prep.(Reuse Onsi te) 30500 SY $1.25 $38,125.00 $1.00 $30,500.00 $1.40 $42,700.00 $1.00 $30,500.00 24 Native Seedi ng 30500 SY $2.10 $64,050.00 $0.90 $27,450.00 $7.50 $228,750.00 $0.50 $15,250.00 25 Rods Berm 245 LF $23.00 $5,635.00 $25.00 $6,125.00 $42.00 $10,290.00 $25.00 $6,125.00 26 Stabilized Construction Entrance 3 EA $1,200.00 $3,600.00 $3,000.00 $9,000.00 $1,400.00 $4,200.00 $2,000.00 $6,000.00 27 Erosion Control Log 1800 1 LF 1 $8.501 $15,300.00 1 $9.00 $16,200.00 1 $13.00 $23,400.00 $9.00 $16,200.00 BID TABULATION Contract: Dry Branch Tributaries Channel Improvements Continued SHEET:2 of 4 APPROX. Smith Contracting Chasco Constructors Austin Filter Systems ERS of M S ITEM ITEM DESCRIPTION QTY. UNIT 28 Temporary Fencing 1500 LF $4.00 $6,000.00 $4.00 $6,000.00 $5.43 $8,145.00 $7.00 $10,500.00 29 New Fend ng 2835 LF $17.00 $48,195.00 $17.00 $48,195.00 $23.00 $65,205.00 $24.00 $68,040.00 30 Double Gate 3 EA $1,700.00 $5,100.00 $1,500.00 $4,500.00 $2,200.00 $6,600.001 $1,300.00 $3,900.00 31 Permanent Turf Reinforcement Matting 4070 SY $8.25 $33,577.50 $8.00 $32,560.00 $9.00 $36,630.00 $13.00 $52,910.00 32 Articulated Concrete Block 1900 SY $110.00 $209,000.00 $85.00 $161,500.00 96.00 W $120.00 $228,000.00 33 B arri cades,Si gns& TrafficHandli ng 1 LS $10,000.00 $10,000.00 $5,000.00 $5,000.00 $12,300.00 $12,300.00 $8,500.00 $8,500.00 34 Trench Safety 600 LF $1.00 $600.00 $3.00 $1,800.00 $1.25 $750.00 $24.00 $14,400.00 35 Tree Protection 650 LF $3.00 $1,950.00 $3.50 $2,275.00 $4.00 $2,600.00 $6.00 $3,900.00 36 Total Mobilization(Not To Exceed 5%) 1 LS $60,000.00 $60,000.00 $60,000.00 $60,000.00 $50,000.00 $50,000.00 $69,000.00 $69,000.00 TOTAL BASE BID: $1,253,162.50 $1,279,975.00 a« $1,383,310.00 ADD ALTERNATE 1 APPROX. UNIT UNIT UNIT UNIT ITEM 4 ITEM DESCRIPTION QTY. UNIT PRICE COST PRI CE COST PRI CE COST PRI CE COST Al Gravity Block Wall 320 LF $500.00 $160,000.00 $384.00 $122,880.00 $438.00 $140,160.00 $1,500.00 $480,000.00 TOTAL ADD ALTERNATE NO.1: $160,000.00 $122,880.00 $140,160.00 $480,000.00 ADD ALTERNATE 2 APPROX. UNIT UNIT UNIT UNIT ITEM 4 ITEM DESCRIPTION QTY. UNIT PRICE COST PRI CE COST PRI CE COST PRI CE COST A2 FI exi bl e Erosi on Control BI anket 17260 SY $3.50 $60,410.00 $1.95 $33,657.00 $2.00 $34,520.00 $4.00 $69,040.00 TOTAL ADD ALTERNATE NO.2: $60,410.00 $33,657.00 $34,520.00 $69,040.00 ADD ALTERNATE 3 APPROX. UNIT UNIT UNIT UNIT ITEM ITEM DESCRIPTION QTY. UNIT PRI CE COST PRICE COST PRICE COST PRICE COST A3 Concrete Block Erosion Control Mat 1900 SY $80.00 $152,000.00 $70.00 $133,000.00 $64.00 $121,600.00 No Bid No Bid TOTAL ADD ALTERNATE NO.3: $152,000.00 $133,000.00 $121,600.00 No Bid I OTHER TOTALS BASE BI D+ADD ALTERNATE 1: $1,319,822.50 $1,320,285.00 milli $1,683,810.00 BASE BI D+ADD ALTERNATES 1& 2: $1,354,342.50 $1,328,052.00 3.. $1,709,700.00 Bold and Underline indicatesslight misspelling in written unit price;but unit price did not appear in doubt. i talicsand under Iine($XXXX. Y)i ndi cate wr itten unit pr i ce differ ed from unit price figures on Bid Form. Fill indicatesadjustment due tocorrection(s). THE CITY OF ROUND ROCK BIDS EXTENDED AND CHECKED Utilities& Environmental Services 2008 Enterprise Drive BY: Jorae R.& DLH Round Rods, Texas 78664 DATE: 4/10/2018 BID TABULATION (CONTINUED) SHEET: 3of4 CONTRACT : Dry Branch Tributaries Channel I m rovements Thyssen-Laughlin D&S Concrete Contractors LOCATION : 2008 Enterprise Drive Statement of Safety?Yes Statement of Safety?Yes Statement of Safety? Statement of Safety? DATE:4/10/2018 Addenda?Yes Addenda?Yes Addenda? Addenda? TIM E:2:00 m Bid Bond?Yes Bid Bond?Yes Bid Bond? Bid Bond? BASE BI D APPROX. UNIT UNIT UNIT UNIT ITEM 4 ITEM DESCRIPTION QTY. UNIT PRI CE COST PRI CE COST PRICE COST PRI CE COST 1 Preparing Right of Way 7 AC $8,950.00 $62,650.00 $10,700.00 $74,900.00 $0.00 $0.00 2 Channel Excavation 15300 CY $20.75 $317,475.00 $25.00 $382,500.00 $0.00 $0.00 3 Embankment 5490 CY $9.75 $53,527.50 $18.00 $98,820.00 $0.00 $0.00 4 Conc.Structures(24" RCP Headwall) 3 CY $2,720.00 $8,160.00 $1,000.00 $3,000.00 $0.00 $0.00 5 Conc.Structures(42" RCP Headwall) 3 CY $2,720.00 $8,160.00 $1,000.00 $3,000.00 $0.00 $0.00 6 Conc.Structures(12" PVC Headwall) 0.5 CY $2,400.00 $1,200.00 $1,000.00 $500.00 $0.00 $0.00 7 Concrete For Structures(Apron Slabs) 250 SY $267.00 $66,750.00 $120.00 $30,000.00 $0.00 $0.00 8 Conc.Structures(Drop Structure) 1 CY $2,600.00 $2,600.00 $1,000.00 $1,000.00 $0.00 $0.00 9 Conc.Structures(Trench Drain) 1 EA $13,440.00 $13,440.00 $3,000.00 $3,000.00 $0.00 $0.00 10 Manhole Adjustments 4 EA $1,200.00 $4,800.00 $4,000.00 $16,000.00 $0.00 $0.00 11 New M anhol e Constructi on,60" DIA 1 EA $4,675.00 $4,675.00 $18,000.00 $18,000.00 $0.00 $0.00 12 New Manhole Construction,48" DIA 1 EA $6,350.00 $6,350.00 $15,000.00 $15,000.00 $0.00 $0.00 13 R pe,24" RCP 75 LF $60.75 $4,556.25 $400.00 $30,000.00 $0.00 $0.00 14 R pe,42" RCP(Reuse Exi sti ng Ri pe) 150 L F $159.25 $23,887.50 $500.00 $75,000.00 $0.00 $0.00 15 Pipe, 12" DIA Steel Casing 60 LF $114.00 $6,840.00 250.00 $15,000.00 $0.00 $0.00 16 Ripe,6" DIA SDR-26 PVC 220 LF $27.50 $6,050.00 $60.00 $13,200.00 $0.00 $0.00 17 Pipe, 12" DIA SDR-26 PVC 442 LF $37.25 $16,464.50 $100.00 $44,200.00 $0.00 $0.00 18 Pipe, 18" DIA Steel Casing 125 LF $101.00 $12,625.00 $350.00 $43,750.00 $0.00 $0.00 19 Dry Rock Ri prap 240 SY $108.00 $25,920.00 $350.00 $84,000.00 $0.00 $0.00 20 Dry Rock Ri prap(New Tri ckl e Channel) 729 SY $54.00 $39,366.00 $350.00 $255,150.00 $0.00 $0.00 21 Gabion Baskets 359 CY $400.00 $143,600.00 $250.00 $89,750.00 $0.00 $0.00 22 Soil Retention Blanket 17260 SY $1.50 $25,890.00 $2.00 $34,520.00 $0.00 $0.00 23 Topsoil & Seedbed Prep.(Reuse Onsi te) 30500 SY $1.25 $38,125.00 $1.00 $30,500.00 $0.00 $0.00 24 Native Seeding 30500 SY $1.25 $38,125.00 $1.00 $30,500.00 $0.00 $0.00 25 Rock Berm 245 LF $25.75 $6,308.75 $50.00 $12,250.00 $0.00 $0.00 26 Stabilized Construction Entrance 3 EA $1,380.00 $4,140.00 $2,000.00 $6,000.00 $0.00 $0.00 27 Erosion Control Log 1800 LF $3.00 $5,400.00 $7.00 $12,600.00 $0.00 $0.00 28 Temporary Fend nq 1500 LF $4.001 $6,000.00 1 $4.00 $6,000.00 $0.001 1 $0.00 BID TABULATION Contract: Dry Branch Tributaries Channel I mprovements(Continued) SHEET:4 of 4 APPROX. Thyssen-Laughlin D&S Concrete Contractors ITEM 4 ITEM DESCRIPTION QTY. UNIT 29 Nedv Fencing 2835 LF $14.00 $39,690.00 $10.00 $28,350.00 $0.00 $0.00 30 Double Gate 3 EA $600.00 $1,800.00 $5,000.00 $15,000.00 $0.00 $0.00 31 Permanent Turf Reinforcement Matting 4070 SY $5.40 $21,978.00 $5.00 $20,350.00 $0.00 $0.00 32 Articulated Concrete Block 1900 SY $178.75 $339,625.00 $65.00 $123,500.00 $0.00 $0.00 33 Barricades,Signs& Traff i c H andl i ng 1 LS $2,000.00 $2,000.00 $5,000.00 $5,000.00 $0.00 $0.00 34 Trench Safety 600 LF $5.00 $3,000.00 $13.00 $7,800.00 $0.00 $0.00 35 Tree Protection 650 LF $4.50 $2,925.00 $8.00 $5,200.00 $0.00 $0.00 36 Total M obi I i zati on(Not To Exceed 5%) 1 LS $71,000.00 $71,000.00 $85,965.26 $0.00 $0.00 TOTAL BASE BI D: $1,435,103.50 $0.00 $0.00 ADD ALTERNATE 1 APPROX. UNIT UNIT UNIT UNIT ITEM 4 ITEM DESCRIPTION QTY. UNIT PRI CE COST PRICE COST PRI CE COST PRI CE COST Al Gravity Block Wei 1 320 L F $750.00 $240,000.00 $250.00 $80,000.00 $0.00 $0.00 TOTAL ADD ALTERNATE NO.1: $240,000.00 $80,000.00 $0.00 $0.00 ADD ALTERNATE 2 APPROX. UNIT UNIT UNIT UNIT ITEM 4 ITEM DESCRIPTION QTY. UNIT PRICE COST PRI CE COST PRICE COST PRICE COST A2 FI exi bl e Erosion Control BI anket 17260 1 SY $1.25 $21,575.00 $1.50 $25,890.00 $0.00 $0.00 TOTAL ADD ALTERNATE NO.2: $21,575.00 $25,890.00 $0.00 $0.00 ADD ALTERNATE 3 APPROX. UNIT UNIT UNIT UNIT ITEM 4 ITEM DESCRIPTION QTY. UNIT PRI CE COST PRICE COST PRI CE COST PRICE COST A3 Concrete Block Erosion Control Mat 1900 SY $73.00 $138,700.00 $40.00 $76,000.00 $0.00 $0.00 TOTAL ADD ALTERNATE NO.3: $138,700.00 $76,000.00 $0.00 $0.00 OTHER TOTALS BASE BI D+ADD ALTERNATE 1: $1,531,503.50 K`` ,,� $0.00 $0.00 BASE BI D+ADD ALTERNATES 1& 2: $1,527,188.50 :? $0,001 $0.00 Bold and Underline indicatesslight misspelling in written unit price;but unit pricedid not appear in doubt. Bold and Italics indicate written unit price wasentered but figuresfor unit priceor for item total were not entered. Bold,Italics,and Underline indicates unit price entered exceeded the maximum stipulated. Fill indicates adj ustment duet000rrection(s). CERTIFICATE OF INTERESTED PARTIES FORM 1L295 101`1 Complete Nos,1-4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos,1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING I Name of business entity filing form,and the city,state and Country of the business entity's place Certificate Number: of business. 2018-343847 Chasco Constructors Round Rock,TX United States Date Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 04/24/2018 being filed. City of Round Rock Date Acknowledged: 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a description of the services,goods,or other property to be provided Under the contract. Dry Branch Tributaries Dry Branch Tributaries Channel Improvements 4 Nature of interest Narne of Interested Party City,State,Country(place of business) (check applicable) Controlling I Intermediary Charles J Glace,JR.2002 Trust Round Rock,TX United States X Anthony J.Glace 2002 Trust Round Rock,TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION My name is CR A-1 0 KLTA and my date of birth is 1141, My address is (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in q0J County, tate of — on the 06 L 20 –, , 2 day of- -1j--O– (Month) (year) Signatu'reof authorized age6t of contracting business entity (Declarant) [::orms provided by Texas Ethics Commission www.ethics.state.tx,LIS Version V1.0.5523 CERTIFICATE OF INTERESTED PARTIES FORM 3.295 1 of 1 Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING 1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number: of business. 2018-343847 Chasco Constructors Round Rock,TX United States Date Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 04/24/2018 being filed. City of Round Rock Date Acknowledged: 05/10/2018 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a description of the services,goods,or other property to be provided under the contract. Dry Branch Tributaries Dry Branch Tributaries Channel Improvements 4 Nature of interest Name of Interested Party City,State,Country(place of business) (check applicable) Controlling I Intermediary Charles J Glace,JR.2002 Trust Round Rock,TX United States X Anthony J.Glace 2002 Trust Round Rock,TX United States X 5 Check only if there is NO Interested Party. ❑ 6 UNSWORN DECLARATION My name is and my date of birth is My address is (street) (city) (state) (zip code) (country) I declare under penalty of perjury that the foregoing is true and correct. Executed in County, State of on the day of 20 (month) (year) Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.5523