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Contract - Battery Warehouse - 5/9/2019 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 the,`1 U ref� ,ftjf (1,1)day of in the year 201 `. BETWEEN the Owner: City of Round Rock,Texas(hereafter"Owner"or"City") 221 East Main Street Round Rock,Texas 78664 and the Contractor ���.�- c9 i]c t.Nodc ("Contractor") r C e J Pic 50,k-e r YncA i`YY1 r TaKkti ' i Ui The Project is described as: 2016 CDBG Sidewalk Project-Greenhill Subdivision The Engineer is: Matthew Bushak,PE City of Round Rock,Texas 512-341-3318 mbushak a,roundrocktexas.gov 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 � /WI 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 ten ( 10 ) 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 Sixty ( 60 )calendar days from issuance by Owner of Notice to Proceed,subject to adjustments of this Contract Time as provided in the Contract Documents. 1:1 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($500.00 ) for each calendar day that Substantial Completion is delayed after the date(s) specified for Substantial Completion. It is hereby agreed that the liquidated damages to which Owner is entitled hereunder are a reasonable forecast of just compensation for the harm that would be caused by Contractor's failure to achieve Substantial Completion of the Work(or any portion thereof)on or before the date(s)specified for Substantial Completion in the Agreement.It is agreed that the harm that would be caused by such failure,which includes loss of expected use of the Project areas,provision of alternative storage facilities and rescheduling of moving and occupancy dates,is one that is incapable or very difficult of accurate estimation.It is hereby agreed that if Substantial Completion of the Work (or any portion thereof) is not achieved on or before thirty (30) days after the date(s) specified for 0 Substantial Completion in the Agreement,the Owner shall have the option to either collect liquidated damages as set forth herein or to thereafter relyon its remedies under the Contract Documents and at law and in equity, including q Jy/� b without limitation,the recovery of actual damages.The date(s)specified for Substantial Completion of the Work(or any portion thereof)in the Agreement shall be subject to adjustment as provided in the Contract Documents. 3.6 Contractor shall achieve Final Completion of the entire Work no later than ninety ( 90 )calendar days from issuance by Owner of Notice to Proceed. ARTICLE 4 CONTRACT SUM 4.1 Owner shall pay Contractor the Contract Su in current funds for Contractor's performance of the Contract. The Contract Sum shall be on e, h mire c t,1;e -t �1©uiscuuk n 1�(1{ htA tt� irec( V i +hrec C.o(1ar) 3° It,o- 1 - ($ 10 r u11/3,(DO ),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 .If yes,please provide details below: 0 00500 4 2016 Page 2 of 5 Standard Form of Agreement 00307791 -.a 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 laterlater the tenth day the month. an Application for Payment is received by Engineer and O nler than�u� (10th) of next If�.,.,t,�,.........,.. ..... �...�.........,,....,�....�. .,� a...a___ _ --_-_ ..---- after the application date fixed above,payment shall be made by Owner not later than one month after the Engineer I 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 Fonn 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 February 2019 7.1.4 The Specifications are those contained in the Project Manual dated February 2019 7.1.5 The Drawings,if any,are those contained in the Project Manual dated February 2019 7.1.6 The Insurance&Construction Bond Forms of the Contract are those contained in the Project Manual dated February 2019 7.1.7 The Notice to Bidders,Instructions to Bidders,Bid Form,and Addenda,if any,are those contained in the Project Manual dated February 2019 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: NONE 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: Jose(JC)Monelongo II,EIT 2008 Enterprise Dr,Round Rock,TX 78664 512-218-7026 jmontelongo@roundrocktexas.gov 8.3 Contractor's representative is: )echn frt5m14.5 501 is Cada' Ate: 'u:Ve c, fINAkttn. 'I'&501 c6V)- C534-1- oa o� `1�x c -4 0 Q d,r,c�`�t. 0A", 8.4 Neither Owner's nor Contractor's representative shall be changed without ten(10)days'written notice to the �J 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 1 ._J 1 r � ij 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. l 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 UND CK EXAS I c w UreLoufi qq m Printed N e: Printed Name: �c�hvi.�, Gi• 1 a G„4 Title \. ►C4 tiav Title: C"," te►'tiNalry M Date i`�i- mi Date Signed: � � Signed: 5 - ATTEST: City Clerk FOR 1 T ,APPROVE r, AS TO FORM: = ►i Q� �'! _�4r/� City Ayforney 00500 4-2016 Page 5 of 5 Standard Form of Agreement 00307791 1 , ri 00600 INSURANCE AND CONSTRUCTION BOND FORMS BONDS AND INSURANCE INSTRUCTIONS Instruction Sheet 1. Insurance Company must be licensed by State of Texas. 2. Agent signing bonds must be licensed in Texas. 3. Agent signing bonds must have Power of Attorney on behalf of insurance company. 4. If Agent signing bonds has Power of Attorney, but not licensed in Texas, then the bond must be counter-signed by Texas local recording agent. ALL THE ABOVE INFORMATION CAN BE FOUND AT Texas Department of Insurance website—www.tdi.state.tx.us 5. Make sure the dollar amount on both Performance and Payment Bonds match the amount of the Agreement&Bid Form Sheet. 6. Both Performance and Payment Bonds should be signed by Authorized Person. If the contractor is a corporation, then it should be signed by the President or the Vice-President. If the contractor is not incorporated, then it may be signed by the Owner. Please state the title of the authorized person. fi Li PAYMENT BOND • THE STATE OF TEXAS § § KNOW ALL MEN BY THESE PRESENTS: COUNTY OF WILLIAMSON • § That Battery Warehouse j of the City of McAllen County of Hidalgo and State of Texas as Principal, and Insurors Indemnity Company 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 Hundred Twenty Five Thousand Six Hundred Eight Eight and 0 Cents Dollars ($ 125,688.00 ) 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 certain written Agreement with the Owner, dated ` the ' tb-- day of • 014 , 2011 , to which Agreement is hereby referred to and made a part hereof as fai y and to the same extent as if copied at length -� herein consisting of 2016 CDBG Sidewalk Project-Greenhill Subdivision 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 an 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. • Pagel 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 t 1t`` day of M I ,20 lei . Battery Warehouse Insurors Indemnity Company Principal Surety • Arturo Morales Omar Villarreal • Printed Name :ta Title: wner Title: Attorney-In-Fact Address: 501 E. Cedar Ave. Suite F Address: P.O.Box 2683 McAllen,Texas 78501 Waco,Texas 76702-2683 Reside gent of Suret . signature • . . Omar Villarreal Smith-Reagan Insurance Printed Name 148 N. Sam Houston Blvd. Street A,ddress an benito, X 78586 • • Page 2 00620 7-2009 Payment Bond 00090656 • PERFORMANCE BOND TEE STATE OF TEXAS § § KNOW ALL BY THESE PRESENTS: COUNTY OF WILLIAMSON § That Battery Warehouse of the City of McAllen Count of • Hidalgo � � and State of Texas , as Principal, and Insurors Indemnity 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 Hundred Twenty Five Thousand Six Hundred Eight Eight nd 0 Cents . Dollars (S 125,688.00 ) 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: 7 WHEREAS,the Principal has entered into a certain written Agreement with the Owner dated the [et -' day of Gl , 204 to which the Agreement is hereby referred to and made a part hereof as fully and to the same extent as if copied at length herein consisting of 2016 CDBG Sidewalk Project-Greenhill Subdivision •�., C l`anrie.o ';the. rojfect) 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 w- 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 r--� meaning of said Agreement and the Plans and Specifications hereto annexed, them 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 006107.2009 Performance Bond 00990656 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 lit L` day of I'1VI ,20 J' • Battery Warehouse Insurors Indemnity Company • Principal Surety • Arturo Morales Omar Villarreal Printed Name Printed Nam By: • Title: owner Title: Attorney-In-Fact Address: 501 E. Cedar Ave. Suite F �'.U. Box 2683 Address: McAllen,Texas 78501 Waco,Texas 76702-2683 Resfd t� gent of Sure Signature • Omar Villarreal Smith-Reagan Insurance • Printed Name 148 N. Sam Houston Blvd. Street Address San Banito,TX 78586 City, State&Zip Code Page 2 06107.2009 Performance Bond 00090656 N, s INOZMOUff CM'lkilit4 POWER OF ATTORNEY of INSURORS INDEMNITY COMPANY Waco, Texas KNOW ALL PERSONS BY THESE PRESENTS: Number: CNB-33831-00 That INSURORS INDEMNITY COMPANY, Waco, Texas, organized and existing under the laws of the State of Texas, and authorized and licensed to do business in the State of Texas and the United States of America, does hereby make,constitute and appoint Omar Villarreal of the City of San Benito, State of TX as Attorney in Fact with full power and authority hereby conferred upon him to sign, execute, acknowledge and deliver for and on its behalf as Surety and as its act and deed, all of the following classes of document, to-wit: Indemnity, Surety and Undertakings that may be desired by contract,or may be given in any action or proceeding in any court of law or equity: Indemnity in all cases where indemnity may be lawfully given and with full power and authority to execute consents and waivers to modify or change or extend any bond or document executed for this Company. INSURORS INDEMNITY COMPANY By: Attest: ( # , 4 Tammy Tieperm , S cretary Dave E. Talbert, President State of Texas County of McLennan On the 11 day of November, 2014, before me a Notary Public in the State of Texas, personally appeared Dave E. Talbert and Tammy Tieperman,who being by me duly sworn, acknowledged that they executed the above Power of Attorney in their capacities as President, and Corporate Secretary, respectively, of Insurors indemnity Company, and acknowledged said Power of Attorney to be the voluntary act and deed of the o pony. / 44 Omni binise L eniti #.9-1111° 0111610,frultik 8""ibiss CAT*Itotw5/04111 4,4. Moly ID 2231501 at ry Public,State of Texas Insurors Indemnity Company certifies that this Power of Attorney is granted under and by authority of the following resolutions of the Company adopted by the Board of Directors on November 11, 2014: RESOLVED,that all bonds, undertakings,contracts or other obligations may be executed in the name of the Company by persons appointed as Attorney in Fact pursuant to a Power of Attorney issued in accordance with these Resolutions. Said Power of Attorney shall be executed in the name and on behalf of the Company either by the Chairman and CEO or the President, under their respective designation. The signature of such officer and the seal of the Company may be affixed by facsimile to any Power of Attorney, and, unless subsequently revoked and subject to any limitation set forth therein,any such Power of Attorney or certificate bearing such facsimile signature and seal shall be valid and binding upon the Company and any such power so executed and certified by facsimile signature and seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it is validly attached. RESOLVED, that Attorneys in Fact shall have the power and authority, subject to the terms and limitations of the Power of Attorney issued to them, to execute and deliver on behalf of the Company and to attach the seal of the Company to any and all bonds and undertakings, and any such instrument executed by such Attorneys in Fact shall be binding upon the Company as if signed by an Executive Officer and sealed and attested to by the Secretary or Assistant Secretary of the Company. I, Tammy Tieperman, Secretary of Insurors Indemnity Company, do hereby certify that the foregoing is a true excerpt from the Resolutions of the said Company as adopted by its Board of Directors on November 11,2014,and that this Resolution is In full force and effect. I certify that the foregoing Power of Attorney is in full force and effect and has not been revoked. In.Witness Whereof, I have set my hand and the seal of INSURORS INDEMNITY COMPANY on this day of,, Tafrorri leper S'era ; - , NOTE: IF YOU HAVE ANY QUESTION REGARDING THE VALIDITY OR WORDING OF THIS POWER.CF ATTORNEY, PLEASE CALL 800 933 7444 OR WRITE TO US AT P.O.BOX 2683,WACO,TEXAS 76702-2683 OR EMAIL US AT CONIFIRMATIONWNSURORSCOM, e l II ,� o INCH MNIIV c A1rmoits PO Box 32577 Phone:877 816 2800 Waco,Texas 76703-4200 IMPORTANT NOTICE -AVISO IMPORTANTE To obtain information or make a complaint: You may call Insurors Indemnity Company's toll-free Para obtener informacion o para someter una queja: telephone number for information or to make a complaint Usted puede llamar al numero de telefono gratis de at: Insurors Indemnity Company's para informacion o para 1-877-816-2800 someter una queja al You may also write to Insurors Indemnity Company at: 1-877-816-2800 P.O.Box 32577 Usted tanbien puede escribir a Insurors Indemnity Waco,TX 76703-4200 Company: Or 225 South Fifth Street P.O.Box 32577 Waco,TX 76701 Waco,TX 76703-4200 0 You may contact the Texas Department of Insurance to 225 South Fifth Street obtain information on companies,coverages,rights or Waco,TX 76701 complaints at Puede comunicarse con el Departamento de Seguros de 1-800-252-3439 Texas para obtener informacion acerca de companias, You may write the Texas Department of Insurance at: coberturas,derechos o quejas al 1-800-252-3439 Consumer Protection(111-1 A) P.O.Box 149091 Puede escribir al Departamento de Seguros de Texas: Austin,TX 78714-9091 Fax: 512-490-1007 Consumer Protection(111-1 A) P.O.Box 149091 Web: http://www.tdi.texas.gov Austin,TX 78714-9091 Fax: 512-490-1007 E-mail: ConsumerProtection@tdi.texas.gov Web: http://www.tdi.texas.gov PREMIUM OR CLAIM DISPUTES: E-mail: ConsumerProtection@tdi.texas.gov 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 DISPUTAS SOBRE PRIMAS 0 RECLAMOS: contact the Texas Department of Insurance. Si tiene una disputa concemiente a su prima o a un reclamo,debe comunicarse con el agente o la compania ATTACH THIS NOTICE TO YOUR POLICY: primero. Si no se resuelve la disputa,puede entonces comunicarse con el departamento(TDI). This notice is for information only and does not become a part or condition of the attached document. UNA ESTE AVISO A SU POLIZA: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto. insurorsindemnity.com CERTIFICATE OF LIABILITY INSURANCE Instruction Sheet -- 1. CERTIFICATE OF LIABILITY INSURANCE FORM The City of Round Rock's Certificate of Liability Insurance form provided herein or a standard ACORD form. } 2. PRODUCER and INSURED -Please list name, address,phone number and e-mail. 3. COMPANIES AFFORDING COVERAGE — TDI number required. The TDI number can be obtained from the Texas Dept of Insurance Website: http://www.tdi.state.tx.us/.—Company Lookup. Note:Exception to this rule.In certain instances where there is unusual risks involved,Surplus Lines Insurance Carriers can be used. Below are the guidelines: a. Insurance Company does not have to be"licensed in Texas",but they do have to be"eligible for a Texas license." Please verify with the Texas Dept of Insurance Website:http://www.tdi.state.tx.us/.—Company Lookup b. Policy has to be written by licensed surplus lines Agent. Also verify with the Texas Dept of Insurance Website:http://www.tdi.state.tx.us/-Agent Lookup 4. TYPES OF INSURANCE COVERAGE- I CONSTRUCTION CONTRACT: Please double check the General Conditions and the Supplemental General Conditions for the types and amounts of insurance required. The Supplemental General Conditions usually state the following: a. Business Automobile Liability Insurance b. Workers' Compensation and Employers' Liability Insurance c. Commercial General Liability Insurance d. Builders' Risk Insurance— (Generally required for all "vertical" construction. Check with Project Manager for requirements.) FOR ALL OTHER CONTRACTS, PLEASE REFER TO THE INSURANCE SECTION FOR TYPE OF INSURANCE REQUIRED. (For example Engineering Service Contracts usually require"professional liability insurance".) 5. EFFECTIVE DATE &EXPIRATION DATE Please make sure dates are current. 6. City of Round Rock must be listed on the Certificate of Insurance as an additional insured (except Workers Compensation and Builders Risk). 7. Certificate must indicate that the insurance Company must give the City of Round Rock notice of any changes, cancellation, etc. at least thirty(30) days prior to date of change. 8. Make sure Certificate is signed by an Agent Licensed in the State of Texas, this can also be found on the Texas Department of Insurance website—www.tdi.state.tx.us—Agent Lookup. I CERTIFICATE OF LIABILITY INSURANCE Date: TDI number required.Please refer to the PRODUCER: Texas Dept of Insurance website: http://www.tdi.state.tx.us/ COMPANIES AFFORDING COVERAGE TDI Phone: E-mail: A INSURED: C Phone: E-mail: D _ THIS IS TO CERTIFY THAT the Insured named above is insured by the Companies listed above with respect to the business operations hereinafter described,for the types of insurance and in accordance with the provisions of the standard policies used by the companies, and further hereinafter described. Exceptions to the policies are noted below. COCO TYPE n�� env EFFECTIVE EXPIRATION I IMITR OF rVLlirr GrrL�►11YL EXPIRATION���v�� LTR INSURANCE NUMBER DATE DATE GENERAL LIABILITY GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG. $ PERSONAL&ADV.INJURY $ EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ BODILY INJURY(Per person) $ I BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ WORKERS'COMPENSATION STATUTORY LIMITS $ , AND EMPLOYERS'LIABILITY EACH ACCIDENT $ DISEASE-POLICY LIMIT DISEASE-EACH EMPLOYEE $ PROFESSIONAL LIABILITY BUILDERS'RISK INSURANCE OR INSTALLATION INSURANCE DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS/EXCEPTIONS The City of Round Rock is named as additional insured with respect to all policies except `Workers' Compensation and Employers' Liability' and `Professional Liability'. Should any of the above described policies be cancelled or changed before the expiration date thereof,the issuing company will mail thirty(30)days written notice to the certificate holder named below. CERTIFICATE HOLDER: City Manager SIGNATURE OF AGENT LICENSED IN STATE OF TEXAS City of Round Rock 221 E.Main Street I i Round Rock,Texas 78664 s-J Typed Name: License ID: Page 1 00650 10-2010 Certificate of Liability Insurance 00205796 1 1 1 ,�c� CERTIFICATE OF LIABILITY INSURANCE DA07/15/2019 TE YY' 1 J 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(les) must 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 rights to the certificate holder in lieu of such endorsement(s). • CONTACT REYES RUELAS PRODUCER NAME: PI-IONE 956 12-9000 FAx 956 12-0303 TRIPLE R INCOME TAX INSURANCE (A/C.No.Ext): ( IAIC,Nat- 223 W TYLER AVE ADDRESS: TRIPLERFINANCIAL@SBCGLOBAL.NET J HARLIMGEN,TEXAS 78550 INSURER(S)AFFORDING COVERAGE NAIL# INSURERA: PROGRESSIVE COUNTY MUTAL INSURANCE 29203 INSURED INSURER B: BATTERY.WAREHOUSE INSURER C: 501 E CEDAR AVE SUITE F INSURER D: MC ALLEN,TEXAS 78501 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD i 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 SEEN REDUCED BY PAID CLAIMS. 1NSR ADM.SUBR POLICY EFF POLICY EXP LIMITS1 LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER JMM(DDIYYYY) (MMJDD/YYYY) I GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 1 CLAIMS-MADE I I OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP,OPAGG $ POLICY n LOC $ AUTOMOBILE LIABILITY (EOa acB.elde©t)SINGLE L1M€T $ X ANY AUTO BODILY INJURY(Per person) $ 30/60/25 A ALL OWNEO SCHEDULED 00906916-0 07/15/2019 07/15/2020 BODILY INJURY(Per acc`dent) $ AUTOS ,N AUTOS PROPERTY DAMAGE NON-OWNED (Per accident) HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _$ EXCESS LIAB CLAIMS-MADE AGGREGATE S $ DED RETENTIONS WCSTATU OTH WORKERS COMPENSATION TORY LIMITSATU T AND EMPLOYERS'LIABILITY ER - ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N E.L-EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N!A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ Ryes,describe under EL DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS bellow DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(Attach ACORD 10i,Additional Remarks Schedule,If more space Is required) THE CITY OF ROUND ROCK IS LISTED AS ADDTIONAL INSURED WITH REGURDS TO GENERAL LIABILTY AND AUTOMOBILE POLICES • CERTIFICATE HOLDER .CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE C CELLED BEFORE CITY OF ROUND ROCK THE EXPIRATION DATE THEREOF, NOTICE,IN E DELIVERED IN 221 EAST MAIN ACCORDANCE WITH THE POLICY PROVISI N ROUND ROCK TEXAS AUTHORIZED REPRESENTATIVE I -- ACORD 25(2010/05) @ -2010 ACORD CORPORATION. All rights reserved. iThe ACORD name and logo are regist re arks of ACORD I 1 1I I- ® DATE(hIM1DDIYYY'Y) , �'' CERTIFICATE OF LIABILITY INSURANCE 06/27/2019 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 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT REYES RUELAS NAME: TRIPLE R INCOME TAX&INSURANCE PHONE (956)412-9000 FAx ( I T 956 12-0303 (A/C.No.Ext): (MC,No): 223 W TYLER AVE • E-MAIL TRIPLERFINANCIAL@SBCGLOBAL.NET ADDRESS: HARLINGEN,TEXAS 78550 INSURER(S)AFFORDING COVERAGE NAIC# _ INSURER A TEXAS MUTAL INSURANCE COMPANY 22945 INSURED INSURER B: ARTURO MORALES INSURER C: DBA:BATTERY WAREHOUSE INSURER D: 501 E CEDAR AVE SUITE F INSURER E: MC ALLEN TEXAS 78501 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. ' INSRL TYPE OF INSURANCE INSR SUER WVD POLICY NUMBER {MM//DDDYIYYYYI (F MMVDCDIYY Y) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES jEa occurrence) $ CLAIMS-MADE OCCUR • MED EXP(Any one person)_^$ PERSONAL&ADV INJURY $ -_ GENERAL AGGREGATE _$ GENt AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP;OPAGG $ - —1 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ____$ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Pet accident) $ AUTOS 1_AUTOS HIRED AUTOS NON-OWNED PROPERTY raacccident}AMAGE $ AUTOS • $ UMBRELLA DAB OCCUR EACH OCCURRENCE $ EXCESS ME CLAIMS-MADE _AGGREGATE $ _ DED —1 RETENTIONS • S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y(N E L.EACH ACCIDENT $ 1000,000.00 X OFFICER/MEMBER EXCLUDED? NIA 0002033151 06/11/2019 06/11/2020 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE$ 1000,000.00 Eyes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS below , _1 DESCRIPTION OF OPERATIONS t LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,ifmore space Is required) THE CITY OF ROUND ROCK IS LISTED AS ADDITIONAL INSURED WITH REGARDS TO GENERAL LIABILTY. CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF ROUND RACK ACCORDANCE WITH THE POLICY PROVISIONS. 221 EAST MIN AUTHORIZED REPRESENTAT ROUND ROCK,TEXAS 786 78664-5299 iACORD 25(2010/05) ©1988 201 01 D CORPORATION. Ar7igTtts reserved, The ACORD name and logo are istered marks of ACORD i j L 1 ,,---.9 Act:3)Ra' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DLyYYYY) 28-JUN-2019 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 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER • CONTACT NAME: Triple R Income Tag and Insurance (B/N) PHONE No.Fvtl: (956) 412-9000 WO.No): •(956) 412-0303y Triple R Income Tax and Insurance (B/N) • EMAIL • 223 W Tyler Ave ADDRESS: tx.iplerfinancial@sbcglobal.net Harlingen, TX 78550 _ INSURER(S)AFFORDING COVERAGE NAIC# )I INSURERA:Hallmark.Specialty'Insurance Company 26808 INSURED • INSURER B.: — ' ARTURO MORALES BATT INSURER C: v 20:4 E LINCOLN INSURERD: • i Harlingen, TX 78550 INSURER E: . INSURER F: • I 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, I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADUL SUBS POLICY EFF POLICY EXP I INSD WVD POLICY NUMBER JMM/DD/YYYY) (MM/DD/YYYY). LIMITS X COMMERCIAL GENERAL LIABILITY EACHOCCLJRRENCE $ $1,000,000 CLAIMS-MADE Y• OCCUR PREMSES0(Ea occu RENTED $ 100,000 MED HtP(Any one person) $ 5,000 . G•42419213 6/19/19 6/19/20 PERSONAL&ADVINJURY $ $1,000,000 GEN'L AGGREGA'IE LIMIT APPLIES PER; GENERAL AGGREGATE $ $2,000,000 X POLICY PRO I I JECT LOC • PRODUCTS-COMP/OPAGG $ $2,000,000 __ OrHER: $ V AUTOMOBILE LIABILITY • COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROP ERTY DAMAGE $ _ HIRED AUTOS _ AUTOS (Per accident) S • UMBRELLA LIAB _ OCCUR T ^EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED _ RETENTION$ $ WORKERS COMPENSATION PER O'I'H- -- AND EMPLOYERS'LIAHILrrY Y/N • STATUTE ER ANY PROPRIETOR/PART NERiEXECUTI VE EL.EACH ACCIDENT •3 OFFICERIMEMBEREXCLUDED? N/A - (Mandatory In NH) EL DISEASE-EA EMPLOYEE s If yes,describe under ' DESCRIPTION OF OPERATIONS below • EL.DISEASE-POLICY OMIT $ • DESCRIPTION OFOPERATIONSILOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more-space in required) • DRIVEWAY, PARKING AREA OR SIDEWALK PAVING OR REPAVING 204 E LINCOLN, HARLINGEN, TX, 78550 CERTIFICATE HOLDER CANCELLATION CITY OE ROUND ROCK . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 221 EAST MAIN . ACCORDANCE WITH THE POLICY PROVISIONS. • ROUND ROCK, TX 78 664 — AUTHORIZED PRESENTATIVE 7 I • ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD J . . - R- 2,0 Iq - 0111- ice: m : o d%�: witco :=:a, A d �.• O oo N .n N o 00 o r W 4N. 6C7 U M 00 D N N '" a L va ,�,�• � 6A 69 69 6N9 fl) srj �Wy O w �' o 0 0 0 CD `'q i o IToin W W N `OO N M opo [� N d �..� 00 O rqO1 �o N •-r �O N w V• 69 6s 69 69 6s 00 w 7 a h ,-r r 00 oo rn �i n o A • • O C, H U •--� � r h O -+ �p Go!�� r-oc R •Oj 7_ Ef3 64 rA � epi O O O O O O O O bA C• O N N vi O Hj •> y w U n M On kn' ri 64 I/s N v3 M 69 O .•••i p o0 Ic i A. cis C. u 69 �oq Cl 0 0 0 0 0 0 Cl o kr) o y N 69 _ 6s bs Go�j M Q O O O O O O O p 00 O O O O M C- L U00Moe �D �n r +•+ 4ai A CA 69n 69 69 6s 00 00 00 A Uaa.. MSI " Q �� U -q 0 0 0 0 6hs •� Q/ M 69 oq 00 6s V] d GQ H z g U� v� c) >,; u O O "O V1 d• N d- Ty � it L t"' O O �' ?� cC ❑ as �•� W 3 In. 4 z O N O O A 6i Cn cz V p, U O O �+ y H Gri N Ha? CO p O U �" N '0 N N > 3 U o uIj N y Or O QU O fl. N •� O O C, Q O eet 00CZ R- 2,0 Iq - 0111- ice: m : o d%�: witco :=:a, m;co W 0 0 00 0 0 0 0 0 cn oOo M 0 �F 0 V7 0 Oi 0 I CD0 O O\ s►T]r O Q w'A O 00 f,9 69 s9 s9 s9 C) 7'n 6n w O .I o0n, 0 0 0 0 0 x � U •o O F" U �--� oo �s ,-, 0 0 o 0 0 0 0 0 0 Eoq roq ros 4�oq A �Qaa a 0 0 0 0 0 0 0 0 A z 1•--' O O O O .OL" •fir v C>`y •--' Nrj Q\ m s9 I Os R u V] ^ 64 b9 69 6R v� UO �4. Q A O 69 O 69 O C O O O O O A 'C Z4 'n cw�7 ^C .fl a GS 59 64 O O O O O O O O 1� O Cl O O O O O N O L Mfti 64 ER b9 6R Z3 h c/a � • � rq 64 ti 65 w 0 � 0 o 0 0 0 0 0 0 0 o 0 c 0 o e� r•� Cyi NO O O O O O N M� I� aCD F cn O n n O O O O\ L W �D DO 69 69 69 69 Op oq 59 o 0 0 0 0 0 U o ` N O O �n O ol� Iq rs 0 0� 00 00 O C• F O N M n 00 0 O 0 O o O n M kn ell O M O oo �D �D O oo N x �G� 1.0 R Z f O O O H w O d y 00 O O O s4 c� s4 cyn Q� U dN M O O O O 00 r �r A > NCA M O O O O O O O O O ti O C cr, U N all 69 64 69 G44 'Tr 00 y • � O U cC y � C • � C:> 0 O cii o �' �. .i 0. SA 69 00 69 N [/] CC m;co W ROUND ROCK TEXAS TRANSPORTATION April 18, 2019 Mayor Craig Morgan Mayor Pro -Tem Writ Baese Re: 2016 CDBG Sidewalk Project - Greenhill Subdivision Engineer's Recommendation of Award of Contract Dear Mr. Hudder: Councilmembers Tammy Young Rene Flores Matthew Baker Will Peckham Hilda Montgomery City Manager Laurie Hadley Attorney an L. Sheets A total of ten (10) sealed bids were received and opened on April 2, 2019 for the above referenced project. The bids ranged from $120,973.00 to $302,746.10. Battery Warehouse from McAllen, Texas, submitted the lowest bid in the amount of $120,973.00. 1 contacted three references provided by the contractor to confirm their qualifications an experience. After reviewing the contractor's experience and bid price, I recommend award of this project to Battery Warehouse in the amount of $120,973.00. Sincerely, Matt Bushak, P.E. Senior Transportation Engineer Attachments: Certified Bid Tabs CITY OF ROUND ROCK TRANSPORTATION DEPARTMENT • 2008 Enterprise Drive, Round Rock, Texas 78664 (P) 512.2'18.7044 . (F) 5"1.218.5563 . roundrocktexas.gov CERTIFICATE OF INTERESTED PARTIES FORM 1295 loft 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 Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2019-471639 Battery Warehouse McAllen, TX United States Date Filed: 04/03/2019 2 Name of governmental entity or state agency that is a party to the contract for which the form is 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. 000000 Concrete Sidewalks and Driveways 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X - 6 UNSWORN DECLARATION My name is �A�rr, w Etra, a S , and my date of birth is My address is �oU C_ , t� nc_p to Qlf I: --TX —M550.. , .(SA . (street) (ci ) (state) (zip code) (country) I declare under penalty off that the foregoing is tfue and correct. perjury Executed in County, State of _ ( .T on the day of AM 111, 201-2— a (month) (year) o�har'a�i.. PAUZ FINO NLICID4Ss.2022 Signature of authorized agent of contracting business entity (Declarant) Forms provided by Texas Ethics Commission`— www.ethics.state.tx.us Version V1.1,39f8039c Forms provided by Texas Ethics Commission www. ethics. state. tx.us Version V1.1.39f8039c CERTIFICATE OF INTERESTED PARTIES FORM 1295 10f1 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 Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2019-471639 Battery Warehouse McAllen, TX United States Date Filed: 04/03/2019 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. City of Round Rock Date Acknowledged: 04/11/2019 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. 000000 Concrete Sidewalks and Driveways 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. X 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 V1.1.39f8039c