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Contract - Royal Vista, Inc. - 9/28/2023 R-20Z:5- 2q,+ CITY OF ROUND ROCK UTILITIES AND ENVIRONMENTAL SERVICES DEPARTMENT ROUND ROCK TEXAS Project Manual For: Greenbelt Storm Sewer and Waterline Improvements August 2023 Prepared By: City of Round Rock APPRIOWED BY CITY ATTORNEY 00200 BID BOND BID BOND THE STATE OF TEXAS § § KNOW ALL BY THESE PRESENTS: COUNTY OF WILLIAMSON § That Royal Vista. Inc. of the City of Liberty Hill County of Williamson State of Texas as Principal, and SureTec Insurance 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,TEXAS("Owner"), in the penal sum of Five Percent(5%)of the total amount of the Bid of the Principal submitted to the Owner, for the Work described below; for the payment whereof, well and truly to be made, and the said Principal and Surety do herby bind themselves and their heirs, administrators, executors, successors and assigns, jointly and severally,as follows: In no case shall the liability of the Surety hereunder exceed the sum of( Five Percent of Greatest Amount Bid Dollars($ 5% GAB ). THE CONDITIONS OF THIS OBLIGATION ARE SUCH that,whereas,the Principal has submitted the above-referenced Bid to the Owner, for construction of the Work under the "Specifications for Construction of Greenbelt Storm Sewer and Waterline Improvements for which Bids are to be opened at the office of Owner on the 22nd day of August ,20 23 . NOW,THEREFORE,if the Principal is awarded the Contract,and within the time and manner required under the"Instructions to Bidders,"after the prescribed forms are presented to her/him for signature,enters into a written Agreement substantially in the form contained in the Bid Documents,in accordance with the Bid, and files the two (2) bonds with the Owner, one to guarantee faithful performance and the other to guarantee payment for labor and materials,then this obligation shall be null and void,otherwise,it shall be and remain in Rill force and effect. If, however, Principal fails to enter into a written Agreement with the Owner in accordance with the Bid or Principal and Surety fail to timely deliver to Owner the performance and payment bonds required by the Bid Documents, Surety within five(5)business days after receipt of a written demand from Owner shall pay to Owner the full penal sum of this Bid Bond, subject to the limitation described herein. In the event that suit is brought upon this Bond by the Owner and judgment is recovered, said Surety shall pay all costs incurred by the Owner in such suit, including a reasonable attorney's fee to be fixed by the Court. IN WITNESS WHEREOF, the said Principal and Surety have signed this instrument on this the 14th day of the month of August 2023 . Royal Vista, Inc. SureTec Insurance Company Lfincipal Surety Q M- 6 yff-Ix Kimberly D. Wilson Printed Name tt Printed Name By: By: Title: �� j(�t.a,I_ Title: Attorney&Fact Address: 350 CR 260 Address: 2103 CityWest Blvd, Ste 13M Liberty Hill, TX 78642 Houston, TX 77042_ 00200 4-2020 Page 1 Bid Bond 00443638 Reside t Agent of urety: Signature Susan M. Palmer Printed Name 2909 Hillcroft, Ste 200 Street Address Houston, TX 77057 City,State,Zip Page 2 00200 4-2020 Bid Bond 00443638 POA#: 4221021 SureTec Insurance Company LIMITED POWER OF ATTORNEY Know AM Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly organized and existing under the laws of the State of Texas, and having its principal office in Houston, Harris County, Texas, does by these presents make,constitute and appoint Susan M. Palmer,Karen Brooks, Patricia Ann Watson, Rex Anthony Goodman,Kimberly D.Wilson its true and lawful Attorney-in-fact,with full power and authority hereby conferred in its name,place and stead,to execute, acknowledge and deliver any and all bonds, recognizances, undertakings or other instruments or contracts of suretyship to include waivers to the conditions of contracts and consents of surety for,providing the bond penalty does not exceed Five Million and 00/100 Dollars($5,000,000.00) and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President,sealed with the corporate seal of the Company and duly attested by its Secretary, hereby ratifying and confirming all that the said Attorney-in-Fact may do in the premises. Said appointment is made under and by authority of the following resolutions of the Board of Directors of the SureTec Insurance Company: Be it Resolved, that the President,any Vice-President,any Assistant Vice-President,any Secretary or any Assistant Secretary shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attomey(s)-in-Fact to represent and act for and on behalf of the Company subject to the following provisions: Attorney-in-Fact may be given full power and authority for and in the name of and of behalf of the Company, to execute,acknowledge and deliver,any and all bonds,recognizances,contracts,agreements or indemnity and other conditional or obligatory undertakings and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attomey-in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be it Resolved,that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it is attached. (Adopted at a meeting held on 20'x'of April, 1999.) In Witness Whereof, SURETEC INSURANCE COMPANY has caused these presents to be signed by its President,and its corporate seal to be hereto affixed this tom day of March ,A.D. 2023 . F.ANSURETEC INSURANCE COMPANY SUCF Irv!' X q By: Michael C.Keimig,Presiden cc 5 r Za State of Texas ss *�;' j County of Harris ., •''' On this 20th day of March A.D. 2023 before me personally came Michael C.Keimig,to me known,who,being by me duly sworn,did depose and say,that he resides in Houston,Texas,that he is President of SURETEC INSURANCE COMPANY,the company described in and which executed the above instrument;that he knows the seal of said Company;that the seal affixed to said instrument is such corporate seal;that it was so affixed by order of the Board of Directors of said Company;and that he signed his name thereto by like order. .��; ,;•.• TANYA SNEED `�` V, Notary Public State of Texas R.; Commission#t 128571231 Tanya Sneed,Nota ublic Commission Expires 03/30/2021 My commission expires March 30,2027 I,M.Brent Beaty,Assistant Secretary of SURETEC INSURANCE COMPANY,do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney,executed by said Company,which is still in full force and effect;and furthermore,the resolutions of the Board of Directors,set out in the Power of Attorney are in full force and effect. Given under my hand and the seal of said Company at Houston, Texas this 14th is of ust /e __2023 _> A.D. B nt Bea ssistattt cretary Any instrument issued in excess of the penalty stated above is totally void and without any validity. 4221021 For verification of the authority of this power you may call(713)812-0800 any business day between 8:30 am and 5:00,,m CST. SureTec Insurance Company IMPORTANT NOTICE Statutory Complaint Notice/FilingofClaims To obtain information or make a complaint: You may call the Surety's toll free telephone number for information or to make a complaint or file a claim at: 1-866-732-0099. You may also write to the Surety at: SureTec Insurance Company 9500 Arboretum Blvd., Suite 400 Austin,TX 78759 You may contact the Texas Department of Insurance to obtain information on companies, coverage, rights or complaints at 1-800-252-3439.You may write the Texas Department of Insurance at: PO Box 149104 Austin,TX 78714-9104 Fax#: 512-490-1007 Web: http://www.tdi.texas.ciov Email: ConsumerProtecbon(-atdi.texas.gov PREMIUM OR CLAIMS DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact the Surety first. If the dispute is not resolved,you may contact the Texas Department of Insurance. ------------------------------------------------------------------------------------ SIC TX Rider TDI Required Notices rev 09_2021 Page 1 of I 00300 BID FORM BID FORM PROJECT NAME: Greenbelt Storm Sewer and Waterline Improvements PROJECT LOCATION: Round Rock, Texas OWNER: City of Round Rock, Texas DATE: July 12, 2023 Gentlemen: Pursuant to the foregoing Notice to Bidders and Instructions to Bidders, the undersigned bidder hereby proposes to do all the Work, to furnish all necessary superintendence, labor, machinery, equipment, tools, materials, insurance and miscellaneous items, to complete all the Work on which he bids as provided by the attached Bid Documents, and as shown on the plans for the construction of Greenbelt Storm Sewer and Waterline Improvements and binds himself on acceptance of this bid to execute the Agreement and bond for completing said Work within the time stated, for the following prices, to wit: Any addenda issued will be posted with the Project Manual and/or Contract Documents on the City's website at https://www.civcastusa.com/ by the close of business on August 18, 2023 Prior to submitting a bid, the bidder is responsible for determining if any addenda have been issued and for following any instructions in any addenda issued. Bidder acknowledges receipt of the following Addenda by listing Addendum "number" and "date". BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount Traffic Control & SWPPP Items 1 1 LS TEMPORARY IRRIGATION SYSTEM (Including removal) complete in place per TXDOT 170 for Ten Thousand dollars and No cents. $10,000.00 $10,000.00 2 6 MO BARRICADES, SIGNS, AND TRAFFIC HANDLING complete in place per TXDOT 502 for One Thousand Five Hundred dollars and No cents. $1,500.00 $9,000.00 00300-9-2015 Page 1 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 3 8295 SY SEEDING FOR EROSION CONTROL complete in place per CORR 604 for Two dollars and Ninety Five cents. $2.95 $24,470.25 4 8 EA TREE REMOVAL(4"-12" DIA) complete in place per CORR 610 for Five Hundred dollars and No cents. $500.00 $4,000.00 5 25 EA TREE PROTECTION complete in place per CORR 610 for Three Hundred dollars and None cents. $300.00 $7,500.00 6 76 LF ROCK BERM complete in place per CORR 639 for Fourty Five dollars and No cents. $45.00 $3,420.00 7 4 EA STABILIZED CONSTRUCTION ENTRANCE complete in place per CORR 641 for Nine Hundred dollars and No cents. $900.00 $3,600.00 00300-9-2015 Page 2 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 8 366 LF TEMPORARY FENCE, 6 FOOT HIGH, CHAIN LINK (INCLUDES INSTALLATION AND REMOVAL) complete in place per CORR 701 for Twelve dollars and No cents. $12.00 $4,392.00 9 2 EA PROJECT SIGNS (TYPE 2) complete in place per CORR 802 for One Thousand dollars and No cents. $1,000.00 $2.000.00 10 462 LF BIODEG EROSN CONT LOGS (18" DIA), INSTALLATION, MAINTENANCE AND REMOVAL complete in place per SS642 for Sixteen dollars and Fifty cents. $16.50 $7,623.00 11 1 LS CONTRACTOR TO PREPARE, SUBMIT, IMPLEMENT, AND UPDATE STORM WATER POLLUTION PREVENTION PLAN (INCLUDING INSPECTIONS) complete in place per TXR150000 for Twelve Thousand dollars and No cents. $12,000.00 $12,000.00 Storm Sewer Items 12 17 SY REMOVING EXIST. CONCRETE& ROCK RIPRAP complete in place per TXDOT 104 for One Hundred dollars and No cents. $100.00 $1,700.00 00300-9-2015 Page 3 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 13 12 LF REMOVING CONC (CURB AND GUTTER) complete in place per TXDOT 104 for Twelve dollars and No cents. $12.00 $144.00 14 834 CY EXCAVATION (CHANNEL) complete in place per TXDOT 110 for Twenty Eight dollars and No cents. $28.00 $23,352.00 15 12 LF CONC CURB & GUTTER(TY 1) complete in place per TXDOT 529 for One Hundred Twenty dollars and No cents. $120.00 $1,440.00 16 116 LF RAIL (HANDRAIL)(TY F) (INCLUDES REMOVAL OF EXISTING) complete in place per TXDOT 450 for Two Hundred Fifty dollars and No cents. $250.00 $29,000.00 17 2 EA JCTBOX (COMPL)(PJB) (6FTX6FT) complete in place per CORR 506 for Nine Thousand Five Hundred dollars and No cents. $9,500.00 $19,000.00 00300-9-2015 Page 4 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 18 2 EA INLET(COMPL)(PAZD)(FG) (6FTX6FT-4FTX4FT) complete in place per CORR 508 for Fifeteen Thousand dollars and No cents. $15,000.00 $30,000.00 19 1 EA WINGWALL (PW-1)(HW=SFT) (INCLUDING REMOVAL OF EXISTING) complete in place per CORR 508 for Twenty Two Thousand dollars and No cents. $22,000.00 $22,000.00 20 1425 LF TRENCH SAFETY SYSTEMS (ALL DEPTHS)(INCLUDING PREPARATION AND SUBMITTAL OF TRENCH SAFETY PLAN) complete in place per CORR 509 for Eleven dollars and No cents. $11.00 $15,675.00 21 1406 LF RC PIPE (CL III)(48 IN) (ALL DEPTHS) INCLUDING ROCK EXCAVATION, BEDDING AND BACKFILL complete in place per CORR 510 for Two Hundred Forty dollars and No cents. $240.00 $337,440.00 22 65 CY CONCRETE RIPRAP (6") complete in place per CORR 591 for Four Hundred dollars and No cents. $400.00 $26,000.00 00300-9-2015 Page 5 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 23 85 CY RIPRAP (STONE COMMON) (GROUT)(18 IN.) (INCLUDING CHANNEL EXCAVATION) complete in place per CORR 591 for Two Hundred Fifty dollars and No cents. $250.00 $21,250.00 24 3 EA PORTLAND CEMENT CONCRETE RETARDS complete in place per CORR 593 for Four Hundred dollars and No cents. $400.00 $11200.00 25 66 LF TEMPORARY SAFETY FENCE, 6 FOOT, CHAIN LINK (INCLUDES INSTALLATION AND REMOVAL) complete in place per CORR 701 for Twelve Dollars dollars and No cents. $12.00 $792.00 26 66 LF REMOVING AND RELOCATING EXISTING 6 FT. WOODEN FENCE (INCLUDING RE-INSTALLATION OF EXISTING FENCE) complete in place per CORR 702 for Thirty dollars and No cents. $30.00 $1,980.00 00300-9-2015 Page 6 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 27 2 EA CONCRETE SIDEWALK DRAIN (INCLUDES REMOVAL OF EXISTING SIDEWALK) complete in place per SP-6 for Four Thousand Five Hundred dollars and No cents. $4,500.00 $9,000.00 Water Line Items 28 3 SY REMOVING CONC (SIDEWALKS) complete in place per TXDOT 104 for One Hundred dollars and No cents. $100.00 $300.00 29 12 LF REMOVING CONC (CURB AND GUTTER) complete in place per TXDOT 104 for One Hundred Twenty dollars and No cents. $120.00 $1,440.00 30 30 LF ENCASEMENT PIPE, 30" DIA, STEEL complete in place per CORR 505 for Three Hundred Forty dollars and No cents. $340.00 $10,200.00 31 1493 LF TRENCH SAFETY SYSTEMS (ALL DEPTHS)(INCLUDING PREPARATION AND SUBMITTAL OF TRENCH SAFETY PLAN) complete in place per CORR 509 for Six dollars and No cents. $6.00 $8,958.00 00300-9-2015 Page 7 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 32 3 TON DI FITTINGS complete in place per CORR 510 for Eleven Thousand dollars and No cents. $11,000.00 $33,000.00 33 1 EA WET CONNECTIONS 6"X6" complete in place per CORR 510 for Three Thousand Five Hundred dollars and No cents. $3,500.00 $3,500.00 34 1 EA WET CONNECTIONS 12"X 12" complete in place per CORR 510 for Three Thousand dollars and No cents. $3,000.00 $3,000.00 35 1 EA WET CONNECTIONS 16"X 16" complete in place per CORR 510 for Four Thousand dollars and No cents. $4,000.00 $4,000.00 36 71 LF REMOVE 6" WL (UNK) complete in place per CORR 510 for Thirty dollars and No cents. $30.00 $2,130.00 37 72 LF REMOVE 12" WL (UNK) complete in place per CORR 510 for Fourty dollars and No cents. $40.00 $2,880.00 00300-9-2015 Page 8 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 38 68 LF REMOVE 16" WL (UNK) complete in place per CORR 510 for Fou rty Five dollars and No cents. $45.00 $3,060.00 39 17 LF 6" DI WATER LINE, BY OPEN CUT(ALL DEPTHS) (INCLUDING ROCK EXCAVATION, BEDDING AND BACKFILL) complete in place per CORR 510 for Eighty dollars and No cents. $80.00 $1,360.00 40 11 LF 12" WATER LINE, AW WA C900 DR 18, BY OPEN CUT(ALL DEPTHS) (INCLUDING ROCK EXCAVATION, BEDDING AND BACKFILL) complete in place per CORR 510 for One Hundred Fifty Five dollars and No cents. $155.00 $1,705.00 41 177 LF 16" DI WATER LINE, BY OPEN CUT(ALL DEPTHS) (INCLUDING ROCK EXCAVATION, BEDDING AND BACKFILL) complete in place per CORR 510 for Two Hundred Twenty Four dollars and No cents. $224.00 $39,648.00 42 1349 LF 16" WATER LINE,AWWA C900 DR 18, BY OPEN CUT(ALL DEPTHS) (INCLUDING ROCK EXCAVATION, BEDDING AND BACKFILL) complete in place per CORR 510 for Two Hundred Four dollars and No cents. $204.00 $275,196.00 00300-9-2015 Page 9 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 43 1 EA AUTOMATIC COMBINATION AIR/VACUUM RELEASE VALVE ASSEMBLY 2" DIA complete in place per CORR 511 for Eleven Thousand dollars and No cents. $11,000.00 $11,000.00 44 1 EA 6-IN RS GATE VALVE AND INSTALLATION complete in place per CORR 511 for Two Thousand Six Hundred dollars and No cents. $2,600.00 $2,600.00 45 2 EA 16-IN RS GATE VALVE AND INSTALLATION complete in place per CORR 511 for Fifeteen Thousand dollars and No cents. $15,000.00 $30,000.00 46 1 EA FIRE HYDRANTS complete in place per CORR 511 for Nine Thousand Five Hundred dollars and No cents. $9,500.00 $9,500.00 47 1 EA REFLECTORIZED PAVEMENT MARKERS (TYPE II-B-B) complete in place per CORR 511 for Fifeteen dollars and No cents. $15.00 $15.00 00300-9-2015 Page 10 of 12 Bid Form BASE BID Bid Approx. Item Description Item Quantit Unit and Written Unit Price Unit Price Amount 48 12 LF CONC CURB & GUTTER (TY 1) complete in place per TXDOT 529 for One Hundred Twenty dollars and No cents. $120.00 $1,440.00 49 3 SY CONC SIDEWALKS (4") complete in place per TXDOT 531 for Six Hundred dollars and No cents. $600.00 $1,800.00 50 50 CY FLOWABLE BACKFILL complete in place per TXDOT 401 for Three Hundred Eight Three dollars and No cents. $383.00 $19,150.00 Miscellaneous Items 51 1 LS MOBILIZATION complete in place per CORR 700 for Fifty Thousand dollars and No cents. $50,000.00 $50,000.00 TOTAL BASE BID (Items 1 thru 51 ) $1,143,860.25 - Materials: $629,123.14 All Other Charges: $514,737.11 * Total: $1.143.860.25 * Note: This total must be the same amount as shown above for "Total Base Bid" 00300-9-2015 Page 11 of 12 Bid Form TOTAL BASE BID (Items 1 thru 51 ) $1,143,860.25 Materials: $629,123.14 All Other Charges: $514.737.11 * Total: $1,143,860.25 * Note: This total must be the same amount as shown above for "Total Base Bid" If this bid is accepted, the undersigned agrees to execute the Agreement and provide necessary bonds and insurance certification as per the Instructions to Bidders. The undersigned certifies that the bid prices contained in the bid have been carefully checked and are submitted as correct and final. The Owner reserves the right to reject any or all bids and may waive any informalities or technicalities. Respectfully Submitted, &J I ] P �r2-0 L/110� mod Signature W" nb� Print Name Address Jtxlt CS l'L� 5 Title Telephone Nam of Firm di I —Oil 16 �� Date Secre ary if Bidder is a Corporation 00200-9-2015 Page 12 of 12 Bid Form 00410 STATEMENT OF BIDDER'S SAFETY EXPERIENCE Page 1 00410 8-2014 Statement of Bidder's Safety Experience 00090654 Solicitation Requirements, Contract Forms & Conditions of Contract Statement of Bidder's Safety Experience Section 00410 Bidder must submit a signed Statement of Bidder's Safety Experience form with his Bid; failure to do so will constitute an incomplete Bid that may be rejected. In order to make a responsive Bid, Bidder must provide evidence that it meets minimum OSHA construction safety program requirements, has not been fined by OSHA for any willful safety violations in the past three years, and has a lost time injury rate that doesn't exceed the limits established below. All questions must be answered and data given must be clear and comprehensive. If necessary, questions may be ans red on separate attached sheets. Company Name: - %sem Address: �.�'! �✓Z Phone: Completed by: Date: 2/ Z 1. Does the company have a written construction Safety program? 'es ❑No 2. Does the company conduct construction safety inspections? es No 3. Does the company have an active construction safety-training program? es ❑No 4. Has the company been fined by OSHA for any willful safety violations in the past ❑Yes [�io three years? 5. Does the company have a lost time injury rate of 7.8 for SIC 15,or 7.6 for SIC 16, OYes ❑No or less over the past three years? Attach the company's OSHA 200/300 logs for the past three years. 6. Does the company or affected subcontractors have competent persons in the following Areas? ��►► A. Scaffolding El Yes IVJNo ❑N/A B. Excavation Yes ❑No ❑N/A C. Cranes ❑Yes 931<o ❑N/A D. Electrical ❑Yes 2f%Io ❑N/A E. Fall Protection [/ Yes ❑No ❑N/A F. Confined Spaces E(Yes [:]No ❑N/A I hereby certify that the above information is true and correct. Signatureuta6a_4�,h�AaTitle midu j' Page 1 00410 8-2014 Statement of Bidder's Safety Experience 00090654 OSHA,'s Form 300A (Rev.04/2004) Note:You can type input into this form and save it. Year 20 0 Because the forms in this recordkeeping package are"fillablelwritable" PDF documents,you can type into the input form fields and — H Summary of Work-Related Injuries and Illnesses then save your inputs using the free Adobe PDF Reader, U.S. Department of Labor Occupational Safety and Health Administration All establishments covered by Part 1904 must complete this Summary page,even if no work-related injuries or illnesses occurred during the year. Form approved OMB no.121910176 Remember to review the Log to verify that the entries are complete and accurate before completing this summary. Using the Log,count the individual entries you made for each category. Then write the totals below,making sure you've added the entries from every page of the Log.If you had no cases,write"0." Employees,former employees,and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access Establishment information to the OSHA Form 301 or its equivalent.See 29 CFR Part 1904.35,in OSHA's recordkeeping rule,for further details on the access provisions for Your establishmentname these Street 3 5-bC �� forms- Numbere Total number of Total number ofCity„l J " State Zip_ �flp�L Total number of cases Total number of deaths cases with days with job transfer or other recordable Industry description(e.g.,Manufacture ofmntor truck trailers) away from work restriction cases Q Q Q Q u�J��2�r�ali�;� k7_/UV /L)S c�7 (G) (H) (0 W) North American Industrial Classification(NAILS),if known(e.g.,336212) Number of Days 7 Employment information(Ifyou don't have these figures.see the Total number of days Total number of days of Worksheet on the nest page to estimate.) away from work job transfer or restriction Q Q Annual average number of employees (K) (L) Total hours worked by all employees last yearInjury and Illness Types s% Sign here Knowingly falsifying this document may result in a fine. Total number of... (M) I certify that I have ex a d this docunt and that to the best of (t)Injuries (4) Poisonings Q Q y knowledge the ent s true,accum te,and complete. RF.S/�ENT (2)Skin disorders Q (5) Hearing loss Q 1 Comp executive Title (3)Respiratory conditions Q Ph, Seo? `5 /s' 87e1 Date P Y ' Q (6) All other illnesses Post this Summary page from February 1 to April 30 of the year following the year covered by the form. R"M Public reporting burden for dues collection of information is estimated to average 58 minutes per response,including time to review the instructions.search and gather the data needed.and complete and review the collection of information.Persons arc not required to respond to the collection of information unless it displays a currently valid OMB control number.If you have any comments about these estimates or any other aspects ofthis data collection.contact:US Department of Labor.OSHA OB7cc of Statistical Analysis.Room N-3644.200 Constitution A%enuc.NW, Washington.DC 20210.Do not send the completed forms to this office. Plod OSHA's Form 301 Attention:This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent Injury and ///Hess Incident Report possible while the information is being used for U.S.Department of Labor occupational safety and health purposes. oee"Patien.l sefoty and MV&Mh Administration Fur"-pin U%e ONl It nu.I.18-0176 Information about the employee Information about the case This laway and Illness In(iden.t Repwy is one of the. first foruls you must fill out when a recordable work_ 11 F°u"'"e f I �S L/L C7 7- 10) Case number from the Log �_,r,�„� the a,a nr, I.,h:,�a the Lq iq>-,ps.,,d d—a.,e.) related injury or illness has occurred.Together with 6 8/b 1- <� r t C_ t 11) Date of injury or illness ZDZD the Lose o/Mork-Related Iujttries and Illnesses and the zl snYE1 oIT / 12)Time employee began work W�oO p M ncaunpanving,Snu+nvr»�,these forms help the c;h, A 0g�i � sum_ /�ztP 78 7`Y' employer and OS14Adevelo a picture 13)Time ofevent 3 vel nM! M ❑Check iftime ram,otbedetermined P� p �� and sCCC17ty"Ul W(rt"k-rclatC(I incidents. a) Date of birth�i9-! 19 7R 14) What was the employes doing just before the Incident oosuned?Describe the activity,as well as the lWithin i calendar days after you receive. 4)Date hired Ila!a,-.10/LI tools,equipment,or material the employee w-as using.Be specific.Examples:"climbing a ladder while information that a recordable work-related injury or ecarrying roofing materials";"spearing chlorine from hand sprayer";"daily computer key entry." 51 M.I. illness has.Sone stat you rker'ill out this form m an ; a yyl r nG� �(�e.5 ,yl (�O( Q"t'�GC�, Female J C(III11a1C111.SO111C SMC W/Jl'kC]•S C0111pC11SaC1Ol1, insurance,or other reports may he acceptable substitutes.To he considered an equivalent form, 15) What ha any substitute must contain all the information Information about the physician or other health care et";"W?Tell us how the injury hlorired.henFxaBask "Whet ladder slipped on wet floor,worker fell 20 feet";"Worker was sprayed with chlorine when gasket broke during replacement";"Worker askcd l6v on this lot in. professional developed soreness in wrist over time." According to public Law 91-596 and 29 CPR /- / 6) Name ofphysician or other health care professional 1901,USHA's 1 ecordkeeping rule,you must keep y 1Tl r y Q� Yl Q l SO l vi( this form on file for 5 years following the Lear to which it perp/ins. 7) If treatment was given away from the worksite,where was,it given? 16) What was the injury or iffness?Tell us the part of the body that was affected and how it was affected;be if you need additional copies of this loran,votl n' more specific than"hurt."`'pain,"or sore."F,xamples:"strained back";"chemical burn,hand";"carpal may photocopy and tile.as malty a-,yon heed. Facit tv_i cw /f14—rtunnel syndrome." srreet h 4-a -�)a r) V s�, City.iilJ Sri stale `zip-7 J g t:) What object or substance directly harmed the omployso?Examples:"concrete floor":"chlorine"; +�- )µor employee treated in an emergency room? "radial arm saw."If this question does not apply to the incident,leave it blank. Completed by /`l�.,�al 2t,5 / �No Title 2�S /[.. 9) Was employee hospitalized—might as an in-patient? J Phone, I�--((J Date _�_, O 111�- 18) If the employee died,when did death occur?Date mf death &N&agMW /? Pohl. yrrting Mmirn her rhea"Arman 41-14 patina ix r.rimv.d n.rw ..p, ,+pre .h f h d,nter .,ir, r.hang.-yunnq dao them.,g:nhcnng end msoi lniug d-dn,na .I,d red n.nr I- red n .th,,oda,,, ..r hHnnnninr Fo ra .,I.� rnllectiun rel rutin rnatvtn Inness it des lave a nlrrrrt valid Ohin mnool � � p 'en. ,nh 1� n.l n•rh, p u l+ri.a you have env tt+,nmr�nr:.M+ul rhis rrnmutr o :� rhe aspects°I tort data rollectrnn,mdudhrg ruggedinns.'or reducing this burden,a+ntac I s nepannnrnt of Lalr,r.OSHA OOrr otstamu cal v,ahnis.unnm N-:NrN,Ni10(.,,>t r nr ,.•.n N warhington,UC?0210 Do ua read Iltc tomplemd laws to dda ol.ice. 5pL U E � ��"'- - a �_/ Note:You can type input into this form and save it. Because the forms in this recordkeeping package are"tillable/writable" PDF documents,you can type into the input form fields and S then save your inputs using the free Adobe PDF Reader.In addition, Calculating Injury and Illness Incidence Rate he forms are programmed to auto-calculate as appropriate. What is an incidence rate? _ �� (c)The number of hours all employees actually various classifications(e.g.,by industry,by LV-<_ An incidence rate is the number of recordable worked during the year.Refer to OSHA Form employer size,etc.).You can obtain these 11,f A1 I'i injuries and illnesses occurring among a given 300A and optional worksheet to calculate this t�tJ 1 g g g P published data at www.bls.eov/iif or by calling � number of full-time workers(usually 100 full- number. a BLS Regional Office. S& 5 y time workers)over a given period of time You can compute the incidence rate for all /L'r y w'�:Y5 4 (usually one year).To evaluate your firm's injury recordable cases of injuries and illnesses using the and illness experience over time or to compare following formula: ^wa- your firm's experience with that of your industry Total number of injuries and illnesses X 200,000= as a whole,you need to compute your incidence Number of hours worked by all employees=Total Worksheet rate.Because a specific number of workers and a recordable case rate specific period of time are involved,these rates can help you identify problems in your workplace (The 200,000 figure in the formula represents the Number of and/or progress you may have made in preventing number of hours 100 employees working 40 hours Total number of hours worked Total recordable work-related injuries and illnesses. per week,50 weeks per year would work,and injuries and illnesses by all employees case rate provides the standard base for calculating incidence rates. X 200,000 -f- /J 9� = 0 How do you calculate an incidence ) rate? You can compute the incidence rate for Y'ou can compute an occupational injury and recordable cases involving days away from work, illness incidence rate for all recordable cases or days of restricted work activity orjob transfer (DART)using the following formula: for cases that involved days away from work for your firm quickly and easily.The formula (Number of entries in column H+Number of requires that you follow instructions in paragraph entries in column!)X 200.000_Number of hours (a)below for the total recordable cases or those in worked by all employees=DART incidence rate Number of paragraph(b)for cases that involved days away You can use the same formula to calculate hours worked DART incidence from work,and for both rates the instructions in Number of entries in incidence rates for other variables such as cases by al I employees rate paragraph(c). Column}}+Column I involving restricted work activity(column(!)on (a)To find out the total number gfrecordable Form 300A),cases involving skin disorders 0 injuries and illnesses that occurred during the x 200,000 — g1 � _ (column(M-2)on Form 300A),etc.Just substitute year,count the number of line entries on your the appropriate total for these cases,from Form OSHA Form 300,or refer to the OSHA Form 300A,into the formula in place of the total number 300A and sum the entries for columns(H),(I), of injuries and illnesses. and(J). (b)To find out the number ofinjuries and What can I compare my incidence rate illnesses that involved days away from work, to7 count the number of line entries on your OSHA Form 300 that received a check mark in column The Bureau of Labor Statistics(BLS)conducts a (H),or refer to the entry for column(H)on the survey of occupational injuries and illnesses each �.' � Q OSHA Form 300A. year and publishes incidence rate data by • OSHA's Form 300 (R,,,. 04/2004) Note:You can type input into this form and save it. YP P Attention:This form contains information relating to Log of Work-Related Because the forms in this recordkeeping package are"fiIla ble/writable" employee health and must be used in a manner that PDF documents,you can type into the input form fields and protects the confidentiality of employees to the extent Year 20 then save your inputs using the free Adobe PDF Reader.In addition, possible while the information is being used for Injuries and Illnesses the forms are programmed to auto calculate as appropriate. U.S. Department o/ Labor occupational safety and health purposes. oeeuPar;nna/safety and Health Adm/n;arrarren Please Record: Reminders: Form approved OMB no.1219-0176 •Information about every work-related death and about every work-related injury or illness that involves loss of •Complete an Injury and Illness Incident Report(OSHA Form301)orequivolent consciousness,restricted work activityorjob transfer,days away from work,or medical treatment beyond first aid form for each injury or illness recorded on this form.Ifyou're not sure whether Establishment name •Significant work-related injuries and illnesses that are diagnosed by physician or licensed health care professional. case is recordable,call your local OSHA office for help. • Work-reio led injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 •Feel free to use two lines fora single case ifyou need to. through 1904.12. •Complete the 5 steps for each case. cly star, Step 1.Identify the person Step 2.Describe ONL Y ONE circip has ed on the (A) (B) (C) (D) (E) (F) Enter the number of •' = days the injured or ill Select one column: Case Employee's name Job title Date of injury Where the even[occurred Describe injure or illness,parts of body worker was: no. (e.g..Welder) or onset of (e.g.,Loading dock north end) affected,and object/substance that , Weaa ndirects)injured or made person ill(e.g., Remained at Work ttlucs (e.g.,2/!0) Second degree)urns an right jorearar.jrom �_s_ aceto/ene torch) Days away Job transfer Other record- away on job (M) �� ^11 Death from work or restriction at cease from transfer or (G) (H) (l) (3) iK) restrictiono 1 L2, ��L I moumlday (.� l �!' Cc r I�/) &II 0,AJ -!!ld 0 darn a." 0®00000 Reset ) month/say 0 0 0 0 _days 000000 0 0 0 0 _ears —dors 000000 month I day Resat month/day 0 0 0 0 _days _says 000000 RBset / 0 0 0 0 _days _darn 000000 ronin I say Reset 000000 ._ ronin r env 0 0 0 0 _days _dors Reset momnlday O O O O _nays _nays 000000 RBSBt day 0 0 0 0 _days _,ars 000000 month I Reset 0 0 0 O 000000 nanM/day _days _days Reset nth/day 0 0 0 0 _days _days 000000 mo Public reporting burden for this collection of information Is estimated to average 14 minutes per resprmse,including time to review the Paye totals , O O 0 O O O Q O O O O O instructions,swreh and gather the data needed,and complete and review the catechists of information.Persons art not required k, Add a Form Page respond to the collection of information unless it displays a currently valid OMB control number.ll'you have any comments about these Be sure to trans/er these totals to the Summa page Form 3009 before you post it. d € esumsks or any other aspects of this data collation,contact:IIS Department of labor.OSHA Once of Sutistiol Analysis,Room l Summary P 9 f ) Y p N-3644.200 Constitution Avenue,NW,Washington,DC 26210.Do not send the completes]forms to this office. se a a (t) (2) (3) (4) (5) (6) r � OSHA's Form 300A (Rev.04/2004) Note:You can type Input Into this form and save it Yeah 20 Because the forms in this recordkeeping package are"tillable/writable" 21 PDF documents,you can type into the input form fields and U.S. Department of Labor Summary of Work-Related Injuries and Illnesses then save your inputs using the free Adobe PDF Reader. oacup.tlon.l safety and Health Adminlstratlon . Fonn approved OMB no.1218-0176 Alt establishments covered by Part 1904 must complete this Summary page,even if no work-related injuries or illnesses occurred during the year. Remember to review the Log to verify that the entries are complete and accurate before completing this summary. Using the Log,count the individual entries you made for each category. Then write the totals below,making sure you've added the entries from every page of the Log.if you had no cases,write T." Establishment information Employees,former employees,and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or its equivalent.See 29 CFR Part 1904.35,in OSHA's recordkeeping rule,for further details on the access provisions for Your establishment name Royal Vista Inc these forms. Street 350 CR 260 Nuniber of Cases ,,,,Liberty Hill state TX Zip 78642 Total number of Total number of Total number of cases Total number of deaths cases with days with job transfer or other recordable Industry description(e.g.,Manufacture of motor nock trailers) away from work restriction cases Underground Utility Construction,Water Sewer Drainage O O O O (G) (H) (I) (J) North American Industrial Classification(NAICS),if known(e.g.,3362 12) 1213171101 To Number of Days Employment Information(ff you dont have these figures,see the Total number of days y Total number of days of Worksheet on the nett page to estimate.) away from work job transfer or restriction 28 Annual average number of employees O O Total hours worked by all employees last year 67,407.00 (K) (�) Sign here injury alld II/l)(,ss Types Knowingly falsifying this document may result in a fine. Total number of... I certify that I have exam �#_. ent and that to the best of (M) m wledge the cntric ate,and complet (1)Injuries 0 (4) Poisonings (2)Skin disorders 0 (5) Hearing loss 0 Comp e ecuhve Title >,,t,t 5 —515-6824 Date 02/01/2/022 (3)Respiratory conditions 0 (6) All other illnesses Q Post this Summary page from February 1 to April 30 of the year following the year covered by the form. �t�it Puhlic,cp,naig burden for this collection of information rs estimated to average 58 mmutes per response,including time to renew the instmclions,search and gather the data needed,and complete and review the collection of Information.Persons arc not required to respond to the collection of mfunnatiun unless i1 displays a currently valid OMA connol number.If you have any znmmenis about these aethnatea-any other aspects of this dao collection.contact:US Department of Labor.OSI IA OBice of Statistical.Amlysis.Room N-3644.200 tAn911lltlon Avenues NW, Washington.DC 202M Do not send the compicr-d Pomo no his office. OSHA's Form 300 (Rev. 04/2004) Note:You can type input into this form and save it. Attention:This form contains information relating to Log of Work-Related Because the forms in this recordkeeping package are"fillable/writable•' employee health and must be used in a manner that PDF documents,you can type into the input form fields and protects the confidentiality of employees to the extent Year 20 then save your inputs using the free Adobe PDF Reader.In addition, possible while the information is being used for U.S.Departm— 0 ent of Labor Injuries and Illnesses the forms are programmed to auto-calculate as appropriate. occupational safety and health purposes. otroap.tlon.t Safety end N+aith Administration . --:�� -.c=......r F . y,+�-;p.J'X",sl.t•3*N'9`t rq>^Y4.'h-.. .. I�. . T!'.D'SA+�x'.•.�-ev..T'15"aut<S.r ral^1N i�icL'�".WW<, .•M:.a .. .Pi'"i:lt�r e-.�Yittt"YY't�eW'!a{Gttl9'Ai�'tY4K Tt'AT•xA1JaS�tM+l,4AtRR2Sd�F.."eTi�%•�:....., n�a.0.9M�rt-yR :r!1R+xe,y�iT'.�BFSXI'.i}RlaaaaAl Please Record: Reminders: Form approval OMB no.1218-0176 •Information about every work-related death and about every work-related Injury or illness thatinvolves lossof •Completean Injury and Illness Incident Report(OSHA Form 301)orequivalent consciousness,restricted work activity or/ob transfer,days away from work or medical treatment beyond first aid. form for each injury or illness recorded on this form.Ifyou're not sure whether a Establishment name -Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional, case is recordable,call your local OSHA office for help. •Work-related injuries and illnesses that meet any ofthe specific recording criteria listed in 29 CFR Part 1904.8 •Feel free to use two lines fora single case if you need to. through 1904.12. •Complete the 5 steps for each case. City State Stop 1.Identify file person Step 2.Describe file case Step 3.Classify file case SELECT ®, ONLYONE circle basodon the (A) (B) (C) (D) (E) (F) Enter the number of StHectoneco/umn; Case Employee's name Job title Date of Injury Where the event occurred Describe Injury or Illness,parts of body - ' days the Injured or Ill no. (e.g.,Wetder) or onset of (erg..Loading dock north end) affected,and object/substance that worker was: illness directly injured or made person ill(,g. Remained at Work ' (erg..2.1)0) Second degree burns on right forearm prom 10 a h4ene torch) Oays sway Job tranaHr Other recore- Away On lob (M) Death from work or tistrl.flon able cases from transfer or (G) (H) (I) (J) work(K; restriction 9 `8 None , (1) (2) (3) (4) (5) (6) month/say Re3et 0 0 0 0 _days _days 000000 Rab@t _f nth/day O O O 0 _days _days 000000 mo Resat onth/day m 0 0 0 0 _days _days 000000 Re3et ,_th/d nay O O O O _da s _days 000000 mo met 0 0 0 0 _nayti _days 000000 -- — ynm day Reset month day 0 0 0 0 Ya _days 000000 / Re3ef _f_ month say O 0 O 0 _daya _days 000000 / Re3et l/day f_ mmm� O O O O _days _day: 000000 month O O O 0 _da Ys —data Q 000 00 — /day monthiday O 0 Q _days _tleys 000000 P.1,1 reposing burden for this colkoi.n of usformanct,is csometcd to,wragc 14 mmoics;per response,including lime m rcyiew the Page totals , 0 0 0 O O O Q 0 O 0 0 0 instmctions.,arch and gather the dnla needed,and complete and review the collection of information.Persona arc not r timed to Add a Form Page tcapond to the collection or infonnan-unless it displays a cunemly valid OMB control number.If you have any comments abont thea Be sure to transfer these totals to theSummery page(Form 300A)before you post it. 2 jE eauttntes or any other.,Is"t,of this it.,.collation,castacr US Departmental`Labor.OSHA Once of Statiso,al Analysis,Ron., I 5! N-7644,200 Cotnlitutinn Avenoe,NW N'uhington,DC 20210.Do not semi the compleral forms to thisoffice. — y (1) (2) (3) (4) (5) (6) Note:You can type input into this form and save it. Year 2� Because the forms in this recordkeeping package are"fillable/writable' 21 PDF documents,you can type into the input form fields and . ted Injuries and Illnesses then save your inputs using the free Adobe PDF Reader. U.S.Department of Labor Occupational Safety and Health Administration form approved OMR no.1218-0176 ,.v4 must complete this Summary page,even if no work-related injuries or illnesses occurred during the year. fY that the entries are complete and accurate before completing this summary. .ual entries you made for each category. Then write the totals below,making sure you've added the entries from no cases,write"0." Establishment information .as,and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access z,equivalent.See 29 CFR Part 1904.35,in OSHA's recordkeeping rule,for further details on the access provisions for Your establishmentname Royal Vista Inc street 350 CR 260 CityLiberty Hill state TX Zip 78642 ...,net of Total number of Total number of cases Total number of As cases with days with job transfer or other recordable Industry description(e.g..Manufacture ofniotor truck trailers) away from work restriction cases 0 0 0 0 Underground Utility Construction,Water Sewer Drainage (G) (H) (I) (3) North American Industrial Classification(NAICS),if known(e.g.,336212) 237110 Number of Days Employment information(IJ:you don't have these figures,see the Total number of days Total number of days of Worksheet on file nerr page to estinrale.) away from work job transfer or restriction 0 0 Annual average number of employees 28 (K) Total hours worked by all employees last year 67,407.00 Sign here Injury and Illness .- Knowingly falsifying this document may result in a fine. Total number of... 1 certify that[have exam7'&D nt and that to the best of (M) m wledge the entriete,and colpplet (1)Injuries 0 (4) poisonings 0 (2)Skin disorders 0 (5) Hearing loss 0 Comp c ecunve Title/ (3)Respiratory conditions 0 Pho 5 -515-6824 Date 02/01/2022 P ry 0 (6) All other illnesses Post this Summary page from February 1 to April 30 of the year following the year covered by the form. Reset Public reporting burden for this collection of information is estimated to average 58 minutes per response.including time to review the instructions,search and gather the data needed•and complete and review the collection of information.Persons am not required to respond to the collection of information unless it displays a currently valid OMA control number.If you have any comments about these estimates or any other aspects of this data collection,comael:US Deparin ant of Lahr.OSI IA Oft-ice of Statistical Analysis.Room N-3644.200 Constitution Avenue.NW Washington DC 20210.Donor send the completed forms to this office. r OSHA's Form 300 (Rev. 04/2004) Note:You can type input into this form and save it. Attention:This form contains information relating to LogO of Work-Related Because the forms in this recordkeeping package are"fillable/writable" employee health and must be used in a manner that PDF documents,you can type into the input form fields and protects the confidentiality of employees to the extent Year 20 then save your inputs using the free Adobe PDF Reader.In addition, possible while the information is being used for U.S.Department of Labor Injuries and Illnesses the forms are programmed to auto-calculate as appropriate. occupational safety and health purposes. occupational safety and Health Admihistrat o Please Record: Reminders: Foran approved OMB no. •Information about every work-related death and about every work-related injury or illness that involves loss of •Complete an Injury and Illness Incident Report(OSHA Form 30 1)or equivalent consciousness,restricted work activity orjob transfer,days away from work or medical treatment beyond first aid. form for each injury or illness recorded on this form.Ifyou're not sure whether Establishment name •Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. case is recordable,call your local OSHA office for help. •Work-related injuries and illnesses that meet any of the specific recording criteria listed in 19 CFR Part 1904.8 •Feel free to use two lines for a single case if you need to. through 1904.12. •Complete the 5 steps for each case. city state DescribeStep 1.Identify the person Step 2. SELECT ONLY ONE circle based on the (A) (B) (C) (D) (E) (F) Enter the number of s Case Where the event occurred days the injured or ill Select one column: Employee's name Job title Date of injury Describe injury 0r illness,parts of body worker was: no. (e.g.,Welder) or unset of (e.g.,leading dock north end) affected,and object/substance that illness dircrtly injured or made person ill(e.g., Remained at Work tllncss (e.g..2110) Second degree burns on righ f forearm(ran M acetylene torch) Days away Job transfer other record- Away On job t ) 3 Death from work or,atrlct1.h able cases from transfer or work restriction (G) (H) lI) (J) (K) tea, (1) (2) (3) (4) (5) (6) Reset None / monm/day 0 0 0 0 _days _days 000000 Reset 0 O O O menta say _days _dors 000000 / Reset menta day O O O 0 _days __days 000000 / Reset _ nth I day O O O O _days __days 000000 mo lAay O O O 0 _flava _daya 000000 monm O O O 0 _darn rs 000000 month I day _ga Reset _/_ menta/day O O O 0 _days _days 000000 Reset _ month/day 0 O O O _nays _days 000000 rReset _/— O O O 0 mh I day _days tlays 000000 rr,o Reset - O O O O _daya 000000 month/day Public reposing burden for this coilecriw,of in(onnation is estimated w average l4 minutes per rcsponu.including time m rcview the Page totals , O 0 O O O 0 O O O O O O i-tntctions.search and gather the dam needed,and complete and rcview the collection of information.Persons are not reyuiad to estpond to the collection of ini'onmtian unless it displays a currently valid OMA control number.lryou have any comments about these Add a Form Page Be sure to transfer these totals to the Summary page(Form 300A)before you post it. atitnams man)other aspects of this data collection,contact:US Department of latex.OSHA Office ot'Sutistical Analysis.Room G N-3644.200 Co htwion Avenue,NW',Washington,DC 20210.Do tax send the complo•d Pomo ro his ofce. — j 9 _ =_6 (1) (2) (3) (4) (5) (6) t OSHAr s Form 300A (Rev.04/2004) Note:You can type input into this form and save it Year 2�Zz Because the forms in this recordkeeping package are"fillable/writable" PDF documents,you can type into the input form fields and Summary of Work-Related Injuries and Illnesses then save your inputs using the free Adobe PDF Reader. U.S.Department of Labor Occupational Safety and Hesith Administration R-0 All establishments covered by Part 1904 must complete this Summary page,even if no work-related injuries or illnesses occurred during the year. Form approved OMA no.121 176 Remember to review the Log to verify that the entries are complete and accurate before completing this summary. Using the Log,count the individual entries you made for each category. Then write the totals below,making sure you've added the entries from every page of the Log.If you had no cases,write 0." Establishment Information Employees,former employees,and their representatives have the right to review the OSHA Form 300 in its entirety.They also have limited access t �Q to the OSHA Form 301 or its equivalent.See 29 CFR Part 1904.35,in OSHA's recordkeeping rule,for further details on the access provisions for Y—est bashmenrname these forms. l R_ 1 v(5 If'r— StreetNumber of y 5 7�6 ,- City/�r r ` / tate �_ Zip Total number of Total number of Total number of cases Total number of deaths cases with days with job transfer or other recordable Industry description(e.g.,Manufacnire ofmotor tnic•k trailers) away from work restriction cases 0 0 Q O �tn/� IA-7 7=7TiES (G) (H) (q (,l) North American Industrial Classification(NAICS),if known(e.g.,336212) Number 37r r v Employment information(If vote don't have thesefigures,see the Total number of days Total number of days of Worksheet on the next page to estimate.) away from work job transfer or restriction 0 p Annual average number of employees (K) (L) Total hours worked by all employees last year Sign here Injury and Wriess Types Knowingly falsifying this document may result in a fine. Total l number of... ( I certify that I have examined this document and that to the best of 0 Ml—poy wled the en i are frac,accurate,and complete. (1)Injuries 0 (4) Poisonings(2)Skin disorders 0 (5) Hearing loss Q executive Title DEN (3)Respiratory conditions 0 (6) All other illnesses 0 Phone ori f —S/5— ff 2 Date—) Post this Summary page from February 1 to April 30 of the year following the year covered by the form. @St3t Public reporting burden for this collection of inf—don is estimated to average 58 minutes per response,including time to review the in truclions.search and gather the data needed,ad complete and review the collection of information.Persons arc not required to respond to the collection of inforoution unless n displays a currently valid OMB control number.a you have any comments shout these estimates or any other aspects of this data collection,contact:US Department of Labor.OSHA(Mice of Statistical.Analysis.Room N-3644.200 Constitution Ascnw,NW, Washington,DC 20210.Do not send the compleld forms to this office. • • Note:You can type input into this form and save it. Because the forms in this recordkeeping package are"tillable/writable" PDF documents,you can type into the input form fields and Calculating Injury and Illness Incidence Rates then save your inputs using the free Adobe PDF Reader. addition, the forms are programmed to auto-calculate as appropriate. What is an incidence rate? (c)The numberofhourc all employees actually various classifications(e.g.,by industry,by An incidence rate is the number of recordable worked during the Year.Refer to OSHA Form employer size,etc.).You can obtain these injuries and illnesses occurring among a given 300A and optional worksheet to calculate this published data at www.ols.gov/iif or by calling number of full-time workers(usually 100 full- number. a BLS Regional Office. time workers)over a given period of time You can compute the incidence rate for all (usually one year).To evaluate your firm's injury recordable cases of injuries and illnesses using the and illness experience over time or to compare following formula: your firm's experience with that of your industry Total number of injuries and illnesses X 100,000= as a whole,you need to compute your incidence Number of hours worked by all employees=Total Worksheet ksheet rate.Because a specific number of workers and a recordable case rate specific period of time are involved,these rates i- can help you identify problems in your workplace (The 200,000 figure in the formula represents the Number of and/or progress you may have made in preventing number of hours 100 employees working 40 hours hours worked Total recordable P gre• Y Y p g Total number of work-related injuries and illnesses. per week,50 weeks per year would work,and injuries and illnesses by all employees case rete provides the standard base for calculating How do you calculate an incidence incidence rates.) /, — rate? You can compute the incidence rate for Xeyy X 200,000 –d– O — recordable cases involving days away from work, You can compute an occupational injury and days of restricted work activity orjob transfer illness incidence rate for all recordable cases or (DART)using the following formula: for cases that involved days away from work for your firm quickly and easily.The formula (Number of entries in column H+Number of requires that you follow instructions in paragraph entries in column I)X 100,000_Number of hours (a)below for the total recordable cases or those in worked by all employees=DART incidence rate paragraph(b)for cases that involved days away Number of from work,and for both rates the instructions in You can use the same formula to calculate Number of entries in hours worked DART incidence paragraph(c). incidence rates for other variables such as cases Column H+Column 1 by employeesall rate involvi (a)To.Tnd out the total number of recordable Form 3ng restricted work activity(column(I)on F300A),cases involving skin disorders 0 injuries and illnesses that occurred during the (column(M-2)on Form 300A),etc.Just substitute X 200,000r = year,count the number of line entries on your the appropriate total for these cases,from Form OSHA Form 300,or refer to the OSHA Form 300A,into the formula in place of the total number 300A and sum the entries for columns(H),(I), of injuries and illnesses. � and(J). (b)To find out the number of injuries and What can I compare my incidence rate Reset illnesses that involved days away Prom work, tog J count the number of line entries on your OSHA The Bureau of Labor Statistics(BLS)conducts a Form 300 that received a check mark in column (H),or refer to the entry for column(H)on the survey of occupational injuries and illnesses each Form 300A. year and publishes incidence rate data by OSHA's Form 300 (Rev. 04/2004) Note:You can type input into this form and save it. YP P Attention:This form contains information relating to • Log of Work-Related Because the forms in this recorcikeeping package are"fellable/writable" employee health and must be used in a manner that PDF documents,you can type into the input form fields and protects the confidentiality of employees to the extent Year 20 then save your inputs using the free Adobe PDF Reader.In addition, possible while the information is being used for Injuries and Illnesses programmed pP P occupational safety and health purposes. U.S. Department of Labor the forms are ro rammed to auto-calculate as a ro nate. oeeePanona/Safety and Health Admin/strariot. Please Record: Reminders: Fore,approvcd OMB no.12194)l •Information about every work-related death and about every work-related injury or illness that involves loss of •Complete an Injury and Illness Incident Report(OSHA Form 30 1)or equivalent -.consciousness,restricted workectiviry orjob transfer,days away from work or medical treatment beyond first aid. form for each injury or illness recorded on this form:!(you're not sure whether Esfab/Ishmenr name •Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. case is recordable,call your local OSHA office for help. •Work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 7904.8 •Feel free to use two lines for a single case if you need to. - through 1904.12. •Complete the S steps for each case. city State Step 1.Identify the person Stop 2.Describe the case Step 3.Classify the case SELECT ONLY ONE (A) (B) (C) (D) (E) (F) Enter the number of Case Employee's name Job fludays the injured or ill Select one column: e Date of Injury Where the event occurred Describe injury or ihness,parts of body worker was: no. (e.g..Weldet) or onset of (e.g.,Loading dock north end) affected,and object/substance that Illso. directly injured or made person ill(e.g., Remained at Work d' tit°'ev, (e.g.,2/10) 6,Gond degree burns on right forearm from acetylene torch) Days away Job transfer Other record- Away On Job (M) Death from work or restriction able cases from transfer or 2• g work restriction (G) (H) (I) 0) z e (K) (L) E -- Reset (1) (2) (3) (4) (5) (6) -- month I day O O O O days _dors 000000 Resat / ,th/day � 0 0 days __oar. 000000 Reset — / 0 0 0 0 month/day _days _cars 000000 Reset — month/day 0 0 0 0 _days _days 000000 Reset month day 0 0 0 0 _days _da,, 000000 --. I Re3et , _ mo0 0 0 0 eye _cars nth/tlay 000000 Reset _ month/tlay 0 0 0 0 _days _days 000000 Reset th/day 0 0 0 0 _d aye _days 000000 mon Reset 0 0 0 0 0 000 00 month/day _days _days Reset / O 0 0 0 ,i.w. _dors 000000 month/day Public rcponing burden for this collection of utfomution is estimated to average 14 minutes per response.including time to review the Page totals 11111, O O O O O O O O O O O O inetrUdinns,search and gather the data needed,and complete and resew the collection of information.Persons arc not required to (Add a Form Page respond to the collection or information unless it display,a currently valid OMB control number.11 coo have any comments about mega• I B . annum or any, n other aspens of this data collation,contact:US Department of labor,OSHA Office of Statistical Analysis.Rate e Sure to transfer these rota/s to the Summary page(Form 300A)before you post if W C 2 8 N-36,44,2constimion.Avenue,NN',N'ashmgton.DC 20210.Do not semi the completed form to this office. _ a <- (t) (2) (3) (4) (5) (6) 00500 AGREEMENT 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 V ( )day of 6 in the year 2C �-3 BETWEEN the Owner: City of Round Rock,Texas(hereafter"Owner"or"City") 221 East Main Street Round Rock,Texas 78664 and the Contractor Royal Vista Inc. ("Contractor") 350 CR 260 Liberty Hill,TX 78642 The Project is described as: Greenbelt Storm Sewer and Waterline Improvements The Engineer is: Roberto Erazo,RE LJA Engineering,Inc. 210-503-2725 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 4-2020 Page I of 5 Standard Form of Agreement 00443647 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 ( 1 0 ) 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 hundred fifty1( 50 )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 one thousand and No/100 Dollars($ 1000 ) 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 and is not a penalty. 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 hundred eighty 1( 80 )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 full and complete performance of the Work and all of Contractor's obligations under this Agreement. The Contract Sum shall be one million one hundred and forty three thousand eight hundred sixty dollars and twenty five cents ($ 1,143,860.25 ),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 X . Yes .If yes,please provide details below: 00500 4-2020 Page 2 of 5 Standard Form of Agreement 00443647 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 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. 5.13 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 of amounts approved by the Owner 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.The Owner shall not have any obligation to pay any amount covered by the Engineer's Certificate for Payment that is disputed by the Owner. 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 wan-ant 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 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 and approved by the Owner. 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 General Conditions. 00500 4-2020 Page 3 of 5 Standard Form of Agreement 00443647 6.2 The Work may be suspended by Owner as provided in Article 15 of the 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 tv Ubt �v 7.1.4 The Specifications are those contained in the Project Manual dated riugunt GVGJ 7.1.5 The Drawings,if any,are those contained in the Project Manual dated h U g u N t z uz a 7.1.6 The Insurance&Construction Bond Forms of the Contract are those contained in the Project Manual dated tiugust `vA.3 7.1.7 The Notice to Bidders,Instructions to Bidders,Bid Form,and Addenda,if any,are those contained in the Project Manual dated Aueust 2023 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: Performance and Payment Bonds,Certificate of Insurance 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 Senior Engineer 3400 Sunrise Rd. Round Rock,TX 78665 8.3 Contractor's representative is: Steve Green Vice-President 350 CR 260 Liberty Hill,TX 78642 8.4 Neither Owner's nor Contractor's representative shall be changed without ten(10)days'written notice to the other party. 00500 4-2020 Page 4 of 5 Standard Form of Agreement 00443647 8.5 Waiver of any breach of this Agreement shall not constitute waiver of any subsequent breach. 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 two(2) original copies,of which one is to be delivered to Owner. OWNER CONTRACTOR C17RO R K,TEXAS � �h Ci PrintedJame: ( m Printed Nae: � Wt. Title Title: vim: �r�s Date Signed:�I U1 2,7.� Date Signed: ATTEST: JAI.'I City Clerk FOR CITY,APPROVED AS TO FORM: r" City Attorney' 00500 4-2020 Page 5 of 5 Standard Form of Agreement 00443647 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. 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:htlp://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— 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. Bond #4463088 PERFORMANCE BOND THE STATE OF TEXAS § § KNOW ALL BY THESE PRESENTS: COUNTY OF WILLIAMSON § That Royal Vista,Inc. , of the City of Liberty Hill , County of Williamson , and State of Texas , as Principal,and SureTec 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,One Hundred Forty-Three Thousand, Eight Hundred Sixty and 25/100 Dollars ($ 1,143,860.25 ) 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 Principal has ent red into a certain written Agreement with the Owner dated the &4k� day of ,20 23 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: Greenbelt Storm Sewer and Waterline Improvements 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 4-2020 Performance Bond 00443639 PERFORMANCE 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 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. If Principal fails to faithfully perform said Agreement, Surety, after receipt of written notice of Principal's default,shall perform all of Principal's duties and obligations under the Agreement. If, within ten (10) days after receipt of such notice from Owner, Surety does not commence to complete the obligations of Principal with a contractor acceptable to Owner and diligently complete the performance of the Principal's duties and obligations, Owner shall have the right but not the obligation to have the duties and obligations of Principal performed. In such event, Surety shall pay to Owner,upon demand,all costs,expenses and damages sustained by Owner as a result of Principal's failure to perform its duties and obligations under the Agreement up to the total sum of this Performance Bond, plus all costs and expenses, including attorney's fees and expert and consultant fees incurred by Owner to enforce its rights under this Performance Bond. IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this instrument this 6th day of October , 2023 . Royal Vista,Inc. SureTec Insurance Company Pri ipal Surety �ga _ tica,.i► Kimberly D. Wilson Printed Name Printed Name Byte � �—�= BY: Title: V. Title:lt/wto�ne -Fact Address:350 County Road 260 Address: 2103 CityWest Blvd, Ste 1300 Liberty Hill, TX 78642 Houston,TX 77042 Resident Agent of Surety: Siknature Kimberly D. Wilson Printed Name 2909 Hillcroft, Ste 200 Street Address Houston,TX 77057 City, State&Zip Code Page 2 00610 4-2020 Performance Bond 00443639 Bond #4463088 PAYMENT BOND THE STATE OF TEXAS § § KNOW ALL MEN BY THESE PRESENTS: COUNTY OF WILLIAMSON § That Royal Vista,Inc. ,of the City of Liberty Hill , County of Williamson , and State of Texas , as Principal,and SureTec Insurance 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, TEXAS (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, One Hundred Forty-Three Thousand, Eight Hundred Sixty and 25/100 Dollars($ 1,143,860.25 )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 24& day of d C4C409i2 , 2025 to which 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- Greenbelt £Greenbelt Storm Sewer and Waterline Improvements 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 04-2020 Payment Bond 00437699 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 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 contract,or to the work to be performed thereunder. IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this Instrument this 6th day of October ,20 23 . Royal Vista,Inc. SureTec Insurance Company Principal Surety S"-M \ �wto,• Kimberly D. Wilson Printed Name Printed Name B By: Title: 'Title: Attorne - act Address:350 County Road 260 Address: 2103 CityWest Blvd, Ste 1300 Liberty Hill,TX 78642 Houston, TX 77042 Resident Agent of Surety: Signature Kimberly D.Wilson Printed Name 2909 Hillcroft, Ste 200 Street Address Houston,TX 77057 City, State&Zip Code Page 2 006201-2020 Payment Bond 00090656 POA a: 4221021 SureTec Insurance Company LIMITED POWER OF ATTORNEY Know All Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly organized and existing under the laws of the State of Texas, and having its principal office in Houston, Harris County, Texas, does by these presents make,constitute and appoint Susan M.Palmer,Karen Brooks, Patricia Ann Watson, Rex Anthony Goodman,Kimberly D.Wilson its true and lawful Attorney-in-fact,with full power and authority hereby conferred in its name,place and stead,to execute,acknowledge and deliver any and all bonds, recognizances, undertakings or other instruments or contracts of suretyship to include waivers to the conditions of contracts and consents of surety for,providing the bond penalty does not exceed Five Million and 00/100 Dollars($5,000,000.00) and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President,sealed with the corporate seal of the Company and duly attested by its Secretary, hereby ratifying and confirming all that the said Attorney-in-Fact may do in the premises. Said appointment is made under and by authority of the following resolutions of the Board of Directors of the SureTec Insurance Company: Be it Resolved, that the President, any Vice-President,any Assistant Vice-President,any Secretary or any Assistant Secretary shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attomey(*in-Fact to represent and act for and on behalf of the Company subject to the following provisions: Attorney-in-Fact may be given full power and authority for and in the name of and of behalf of the Company,to execute, acknowledge and deliver,any and all bonds,recognizances,contracts,agreements or indemnity and other conditional or obligatory undertakings and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attorney-in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be it Resolved,that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it is attached. (Adopted at a meeting held on 20'h of April, 1999) In Witness Whereof,, SURETEC INSURANCE COMPANY has caused these presents to be signed by its President,and its corporate seal to be hereto affixed this 2om day of March A.D. 2023 SURETEC INSURANCE COMPANY `ayVRANCFCO�k ,Q`'i' X , By: LU w $ Michael A 4!!5� C.Keimig,Presiden State of Texas ss: ............. fie* County of Harris On this 20th day of March A.D. 2023 before me personally came Michael C.Keimig,to me known,who,being by me duly swom,did depose and say,that he resides in Houston,Texas,that he is President of SURETEC INSURANCE COMPANY,the company described in and which executed the above instrument;that he knows the seal of said Company;that the seal affixed to said instrument is such corporate seal;that it was so affixed by order of the Board of Directors of said Company;and that he signed his name thereto by like order. TANYA SNEED i=,* Notary Public State of Texas "V Commission#128571231 Tana , `•'z•�,N`�' y Sneed Nota ublic Commission Expires 03!30/2021 My commission expires March 30,2027 I,M.Brent Beaty,Assistant Secretary of SURETEC INSURANCE COMPANY,do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney,executed by said Company,which is still in full force and effect;and furthermore,the resolutions of the Board of Directors,set out in the Power of Attorney are in full force and effect. Given under my hand and the seal of said Company at Houston, Texas this 6th a of tobe 2.023 , A.D. B nt Bea ssistant cretar Any instrument issued in excess of the penalty stated above is totally void and without any validity. 4221021 For verification of the authority of this power you may call(713)812-0800 any business day between 8:30 am and 5:00 Fm CST. SureTec Insurance Company IMPORTANT NOTICE Statutory Complaint Notice/FilingofClaims To obtain information or make a complaint: You may call the Surety's toll free telephone number for information or to make a complaint or file a claim at: 1-866-732-0099. You may also write to the Surety at: SureTec Insurance Company 9500 Arboretum Blvd., Suite 400 Austin,TX 78759 You may contact the Texas Department of Insurance to obtain information on companies, coverage, rights or complaints at 1-800-252-3439.You may write the Texas Department of Insurance at: PO Box 149104 Austin, TX 78714-9104 Fax#: 512-490-1007 Web: h2p://www.tdi.texas.gov Email: ConsumerProtecton@tdi.texas.gov PREMIUM OR CLAIMS DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact the Surety first. If the dispute is not resolved,you may contact the Texas Department of Insurance. ------------------------------------------------------------------------------------ SIC TX Rider TDI Required Notices rev 09_2021 Page 1 of I Client#: 12682 ROYVI DATE(MM/DD/YYYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 10/10/2023 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 WANED,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 PRODUCER NAME: Carolyn Ruffeno _ Insurepointe of Texas, Inc. P"oNE 713 964-0022 _ T13 9640044 A/C No Ext) C No 2909 Hillcroft Ste#200 EAWL ADDRESS: cruffenc>@insurepointe.com Houston,TX 77057-5848 INSURER(S)AFFORDING COVERAGE NAIC# 713 964-0022 INSURER A:Conti—ad hu--Company 35289 INSURED INSURER B:Taxan Mutual Irraum—Comparw 22945 Royal Vista Inc. INSURER C conananui Caarulty company 20443 350 County Road 260 INSURER D Liberty Hill,TX 78642-6202 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 CONTRACTOR 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 TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MWD A GENERAL UASU M 7039539353 D612212023 06/2212024 EACHOCCURRENCE $11,000,000 _ X COMMERCIAL GENERAL LIABILITY PREMISES Ea oa rrDence $100,000 CLAIMS-MADE Fx]OCCUR MED EXP(Any one person) $15,000 X PD Ded:2,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE 62,000,000 GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY X PECTRO Loc WorsitePollution POLLUTION $1,000,000 C AUTOMOBILE LIABILITY 7039539336 /22/2023 06/22/202 EOMaBINEI D SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTO Ix AUTOS Per accident $ A X UMBRELLA LIAR X OCCUR 7039539370 0612212023 06/22/2024 EACH OCCURRENCE s5 000 000 EXCESS LIAR CLAIMS-MADE AGGREGATE $5 000 000 DED I X RETENTION$10000 $ B WORKERS COMPENSATION 0001239145 6/22/2023 06/22/202 X WC STATU OTH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N EL.EACH ACCIDENT $11,000,000 OFFICER/MEMBER EXCLUDED? I NJ 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 A Equipment Floater 7039539353 6/22/2023 06122/2024 $675,435 Scheduled $250,000 Rented/leased DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Project: Greenbelt Storm Sewer and Waterline Improvements The General Liability and Automobile policies include a blanket automatic additional insured endorsement that provides additional insured status to the certificate holder only when there is a written contract between the named insured and the certificate holder that requires such status.The General Liability, (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION CI MSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE tyaria Manager g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Round Rock ACCORDANCE WITH THE POLICY PROVISIONS. 221 E. Main Street Round Rock,TX 78664 AUTHORIZED REPRESENTATIVE w, esti ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD #S551224/M542039 CXR DESCRIPTIONS (Continued from Page 1) Workers Compensation and Automobile policies include a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract between the named insured and the certificate holder that requires it. The General Liability,Workers Compensation and Automobile policies include a blanket notice of cancellation to certificate holders endorsement, providing for 30 days advance notice if the policy is cancelled by the company other than for nonpayment of premium, 10 days notice after the policy is cancelled for nonpayment of premium.Notice is sent to certificate holders with mailing addresses on file with the agent or the company.The endorsement does not provide for notice of cancellation if the named insured requests cancellation. The General Liability policy includes an endorsement that contains primary and non-contributory wording.The Umbrella policy is following form. SAGITTA 25.3(2010/05) 2 of 2 #S551224/M542039