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Contract - Austin Traffic Signal Construction - 4/15/2016
Q!J of Round Rr►ck, Texas f'nntran* v Standard Form of Agreement: Section 00500 City of Round Rock, Texas Standard Form of Agreement between Owner and Contractor AGREEMENT made as of the Pday of /.kJ/Y1 ` in the year 201. BETWEEN the Owner: City of Round Rock, Texas (hereafter "Owner" or "City") 221 East Main Street Round Rock, Texas 78664 and the Contractor Austin Traffic Si nal Construction Co, 1, Contractor ) The Project is described as: Signal Construction at Avery -Nelson Blvd CR 112 and A. W. Grimes Blvd. {FM 1460) The Engineer is: HDR Enginceri Inc 810 Resters Crossing # 21 0 Round Rock Texas 78681 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 fonn 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 8-2012 �illl 00196575 Page 1 of 5 Standard Form of Agreement I�ISI 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 ten10 ( ) 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 ninety (90 ) calendar days from issuance by Owner of Notice to Proceed, subject to adjustments of this Contract Time as provided in the Contract Documents. 3.5 If Contractor fails to achieve Substantial Completion of the Work (or any portion thereof) on or before the date(s) specified for Substantial Completion in the Agreement, Contractor shall pay to Owner, as liquidated damages, the sum of five hundred & ninety and No/100 Dollars ($590.00 ) for each calendar day that Substantial Completion is delayed after the date(s) specified for Substantial Completion. It is hereby agreed that the liquidated damages to which Owner is entitled hereunder are a reasonable forecast of just compensation for the harm that would be caused by Contractor's failure to achieve Substantial Completion of the Work (or any portion thereof) on or before the date(s) specified for Substantial Completion in the Agreement. It is agreed that the harm that would be caused by such failure, which includes loss of expected use of the Project areas, provision of alternative storage facilities and rescheduling of moving and occupancy dates, is one that is incapable or very difficult of accurate estimation. It is hereby agreed that if Substantial Completion of the Work (or any portion thereof) is not achieved on or before thirty (30) days after the date(s) specified for Substantial Completion in the Agreement, the Owner shall have the option to either collect liquidated damages as set forth herein or to thereafter rely on its remedies under the Contract Documents and at law and in equity, including without limitation, the recovery of actual damages. The date(s) specified for Substantial Completion of the Work (or any portion thereof) in the Agreement shall be subject to adjustment as provided in the Contract Documents, 3.6 Contractor shall achieve Final Completion of the entire Work no later than one hundred and twenty 120 ) calendar days from issuance by Owner of Notice to Proceed. ARTICLE 4 CONTRACT SUM 4.1 Owner shall pay Contractor the Contract Sum in current funds for Contractor's performance of the The Contract Sum shall be "R_ZO lrk•_n�r•� "�ln:r4u—St,i•�. -tL,o.�e�.,,P c.1�� µ�.�.o^. 1 - 4.2 The Contract Sum is based upon the following alternates which are described in the Contract Documents and are hereby accepted by Owner: FA Page 2 of 5 ARTICLE 5 PAYMENTS 5.1 PROGRESS PAYMENTS 5.1.1 Based upon Applications for Payment submitted to Engineer and Owner by Contractor, and Certificates for Payment issued by Engineer and not disputed by Owner and/or Owner's lender, Owner shall make progress payments on account of the Contract Sum to Contractor as provided below, in Article 14 of the City of Round Rock General Conditions, and elsewhere in the Contract Documents. 5.1.2 The period covered by each Application for Payment shall be one calendar month ending on the last day of the month. 5.1.3 Provided that an Application for Payment is received by Engineer and Owner, and Engineer issues a Certificate of Payment not later than the tenth (10th) day of a month, Owner shall make payment to Contractor not later than the tenth (10th) day of the next month. If an Application for Payment is received by Engineer and Owner after the application date fixed above, payment shall be made by Owner not later than one month after the Engineer issues a Certificate for Payment. 5.1.4 Each Application for Payment shall be based on the most recent schedule of values submitted by Contractor in accordance with the Contract Documents. The schedule of values shall allocate the entire Contract Sum among the various portions of the Work. The schedule of values shall be prepared in such form and supported by such data to substantiate its accuracy as Engineer and Owner may require. This schedule, unless objected to by Engineer or Owner, shall be used as a basis for reviewing Contractor's Applications for Payment. 5.1.5 Applications for Payment shall warrant the percentage of completion of each portion of the Work as of the end of the period covered by the Application for Payment. 5.1.6 Subject to other provisions of the Contract Documents, the amount of each progress payment shall be computed as provided in Article 14 of the City of Round Rock General Conditions. 5.1.7 Except with Owner's prior written approval, Contractor shall not make advance payments to suppliers for materials or equipment which have not been delivered and stored at the site. 5.2 FINAL PAYMENT 5.2.1 Final payment, constituting the entire unpaid balance of the Contract Sum, shall be made by Owner to Contractor when: .1 Contractor has fully performed the Contract except for Contractor's responsibility to correct Work, and to satisfy other requirements, if any, which extend beyond final payment; and 2 a final Certificate for Payment has been issued by Engineer. 5.2.2 Owner's final payment to Contractor shall be made no later than thirty (30) days after the issuance of Engineer's final Certificate for Payment. In no event shall final payment be required to be made prior to thirty (30) days after all Work on the Contract has been fully performed. Defects in the Work discovered prior to final payment shall be treated as non -conforming Work and shall be corrected by Contractor prior to final payment, and shall not be treated as warranty items. ARTICLE 6 TERMINATION OR SUSPENSION 6.1 The Contract may be terminated by Owner or Contractor as provided in Article 15 of the City of Round Rock General Conditions. 4"* Page 3 of 5 6.2 The Work may be suspended by Owner as provided in Article 15 of the City of Round Rock General Conditions. ARTICLE 7 ENUMERATION OF CONTRACT DOCUMENTS 7.1 The Contract Documents, except for Modifications issued after execution of this Agreement, are enumerated as follows: 7.1.1 The Agreement is this executed version of the City of Round Rock, Texas Standard Form of Agreement between Owner and Contractor, as modified. 7.1.2 The General Conditions are the "City of Round Rock Contract Forms 00700," General Conditions, as modified. 7.1.3 The Supplementary, Special, and other Conditions of the Contract are those contained in the Project Manual dated N/A 7.1.4 The Specifications are those contained in the Project Manual dated July 29, 2015 7.1.5 The Drawings, if any, are those contained in the Project Manual dated July 29, 2015 7.1.6 The Insurance & Construction Bond Forms of the Contract are those contained in the Project Manual dated Jigly 29.2015 7.1.7 The Notice to Bidders, Instructions to Bidders, Bid Form, and Addenda, if any, are those contained in the Project Manual dated July 29. 2015 7.1.8 If this Agreement covers construction involving federal funds, thereby requiring inclusion of mandated contract clauses, such federally required clauses are those contained in the "City of Round Rock Contract Forms 03000," Federally Required Contract Clauses, as modified. 7.1.9 Other documents, if any, forming part of the Contract Documents are as follows: N/A ARTICLE 8 MISCELLANEOUS PROVISIONS 8.1 Where reference is made in this Agreement to a provision of any document, the reference refers to that provision as amended or supplemented by other provisions of the Contract Documents. 8.2 Owner's representative is: Bill Stablein City of Round Rock 2008 Enterprise Drive Round Rock, Texas 78664 t 8.3 Contractor's representative is: 1 8.4 Neither Owner's nor Contractor's representative shall be changed without ten (10) days' written notice to the other party. 8.5 Waiver of any breach of this Agreement shall not constitute waiver of any subsequent breach. Page 4 of 5 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 fimds 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 parries, by execution of this Agreement, bind themselves, their heirs, successors, assigns, and legal representatives for the full and faithful performance of the terms and provisions hereof. This Agreement is entered into as of the day and year first written above and is executed in at least three (3) original copies, of which one is to be delivered to Contractor, one to Engineer for use in the administration of the Contract, and the remainder to Owner. OWNER CONTRACTOR CITY F OUND ROCK, TEXAS Austin Traffic Signal Construction Printed Name: Alan McGraw Title City Mayor Date Signed: 4- .15 - I'L ATTEST: _ . (-4, - City Clerk Printed Title: Date Signed: Page 5 of 5 0'/ co M Bond Number: 82440467 CI ISSUED IN FIVE (5) COUNTERPARTS PERFORMANCE BOND THE STATE OF TEXAS KNOW ALL BY THESE PRESENTS: COUNTY OF WILLIAMSON That Austin Traffic Signal Construction Company. Inc of the City of Pflugerville , County of , and State of Travis , as Principal, and Federal 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 Two Hundred Thirty Seven Thousand Seven Hundred Sixty One and 00/100 Dollars ($ 237,761.00 ) for the payment whereof, well and truly to be made the said Principal and Surety bind themselves, and their heirs, administrators, executors, successors and assigns, jointly and severally, by these presents: WHEREAS, the Principal has entered into a certain written Agreement with the Owner dated the I�� %L* day of "4, , 2016 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: Signal Construction at Avery -Nelson Blvd./CR 112 and A.W. Grimes Blvd. (FM 1460) 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 (l 2) 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, HOWF,VER, 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. 00610 7.2009 00090656 Page 1 Pcrfonnancn Bond PERFORMANCE BOND (continued) Surety, for value received, stipulates and agrees that no change, extension of time, alteration or addition to the term of the Agreement, or to the Work performed thereunder, or the Plans, Specifications, or drawings accompanying the same, shall in anywise affect its obligation on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the Agreement, or to the work to be performed thereunder. IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this instrument this day of 1777 A C L-:: 20/[ x. Austin Traffic Signal Construction Co, Inc. Principal Print Name�� _i��' 11r1 Title: _ Address: a Resident Agent of Surety: Si nature Printed Name Pon )Q-% S 4 v cs -S ) ` I / A). NPa d/ n) I A,AQ PLD Street AddrPca Page 2 FEDERAL INSURANCE COMPANY Surety � Printed Name By: Title: 1a c-4 Address: IJ Performance Bond Bond Number: 82440467 ISSUED IN FIVE (5) COUNTERPARTS PAYMENT BOND THE STATE OF TEXAS § § KNOW ALL MEN BY THESE PRESENTS: COUNTY OF WILLIAMSON § ThatAustin Traffic Signal Construction Company, Inc, of the City of Pflugerville , County of , and State of Travis as Principal, and Federal 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, (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 Two Hundred Thirty Seven Thousand Seven Hundred Sixty One and 00/100 Dollars ($ 237,761.00 ) for the payment whereof, well and truly be made the said Principal and Surety bind themselves and their heirs, administrators, executors, successors, and assigns, jointly and severally, by these presents: WHEREAS, the��cipal has entered into a ce n written Agreement with the Owner, dated the lf) 40 _ day of _goad aiY'V. , 2016 , 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: Signal Construction at Avery -Nelson Blvd./CR 112 and A.W. Grimes Blvd. (FM 1460) :)W, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if the said incipal shall well and truly pay all subcontractors, workers, laborers, mechanics, and suppliers, monies to them owing by said Principals for subcontracts, work, labor, equipment, supplies d materials done and furnished for the construction of the improvements of said Agreement, ;n this obligation shall be and become null and void; otherwise to remain in full force and ect. .OVIDF.D, HOWEVER, that this bond is executed pursuant to the provisions of Chapter 2253, xas Government code, as amended, and all liabilities on this bond shall be determined in ,ordance with the provisions of said Chapter 2253 to the same extent as if it were copied at igth herein. !0 7-2009 80656 Page 1 Payment Bond PAYMENT BOND (continued) Surety, for value received, stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Agreement, or to the Work performed thereunder, or the plans, specifications or drawings accompanying the same shall in anywise affect it's obligation on this bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of the contract, or to the work to be performed thereunder. IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this Instrument this '-�"klay ofJ22nom., 20L Traffic Signal Construction Co, Inc, Agent of Surety: 6b5U Page 2 FEDERAL INSURANCE COMPANY Surety Printed Name By: Title: -0, Address: 1. �(Y�v ��'kc � {l Vi et o i - _U 3 ai't jc!� � Looria Payment Bond Client#: 148784 AUSTITRA1 CD rM CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 3H5M/DDN ;CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ITIFICATE DOES NOT AFFIRMATIVELY Ol NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES pW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 'RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the ;ificate holder in lieu of such endorsement(s). ICER southwest Austin B N. Capital of TX Hwy #200 in, 78731 151--77 555 CONTACT NAME: Cindy Ellis PHONE AICA Lo, Ext): 512 451-7555 ac, No : 512 467-0113 ADDRESS: cindy-ellis@usi.biz INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Zurich American Insurance Co. 16535 ED Austin Traffic Signal Construction Co., Inc. & ATS Drilling, Inc. P.O. Box 130 INSURER B, American Guarantee & Liability 26247 l Insurance Company an C INSURER C: Fep y 20281 INSURER D: Round Rock, TX 78680 INSURER E: PERSONAL & ADV INJURY $1,000,000 INSURER F: NERAGES CERTIFICATE NUMBER: REVISION NUMBER: HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD VDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, :XCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR GL0483972304 3/01/2016 03/01/2017 EACH OCCURRENCE $1,000,000 PREMISES (Ea RENTED ) $100,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY X JECT LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ OTHER: AUTOMOBILE LIABILITY BAP483972404 3/01/2016 03/01/201 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURYPer accident $ ( ) X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident X UMBRELLA LIABX OCCUR AUC549084904 3/01/2016 03/01/201 EACH OCCURRENCE $20 000 000 EXCESS LIAB CLAIMS -MADE AGGREGATE s20:000:000 DEDRETENTION $ $ WORCOMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIR/PER/EXECUTIVE OFFICEPoMEMBMBER EXCLUXCLUDED? � Mandatory in NH) "Eadescribe under SC RIPTION OF OPERATIONS below Installation Floater -F1 N / A WC483972204 06639633 3/01/2016 3/01/2016 03/01/201 03/01/2017 PER OTH- XSTATUTE IER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 $100,000 limit $1,000 deductible � 1 -1. - �-- � I I- "'" Ur OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) #1798, Signal Construction at Avery -Nelson Blvd/CR 112 & A.W. Grimes Blvd. (FM 1460) kGeneral Liability and Auto policies include a blanket automatic Additional Insured endorsement that L . 5 Additional Insured status to the Certificate Holder (and other entities as required by the Prime tract), only when there is a written contract that requires such status and only with regard to work onned on behalf of the named insured. The General Liability, Auto and Workers Compensation policies Attached Descriptions) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Round Rock, Texas Attu: Ci THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Manager ACCORDANCE WITH THE POLICY PROVISIONS. 221 E Main Street Round Rock, TX 78664 AUTHORIZED REPRESENTATIVE l025,(2014101) ©1988-2014 ACORD CORPORATION. All rights reserved. ft1441951/IUI1732614f 2 The ACORD name and logo are registered marks of ACORD CLEHB CERTIFICATE OF INTERESTED PARTIES FORM 1295 10f1 Complete Nos. 1- 4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties. CERTIFICATION OF FILING Certificate Number: 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. 2016-15311 Austin Traffic Signal Const. Co, Inc. Pflugerville, TX United States Date Filed: 02/18/2016 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. City of Round Rock Date Acknowledged: 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the goods or services to be provided under the contract. Avery Nelson -CR 112- AW Grimes Traffic Signal - Signage - Lighting installation 4 Name of Interested Panty City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct. ?o1Ppy pUBGO Celia Gutierrez Notary Public, State of Texas My Commission Expires July 31, 2018 Signature of authorized agent of contfcting business entity AFFIX NOTARY STAMP / SEAL ABOVE / Sworn to and subscribed before me, by the said l ae-i (Vl�f I I � 1' � D S this the j day of Gr i 20—/ to certify which, witness my hand and seal of office. 4� C�i.��,. J,.1!r �✓/,%ii.ily4.`� ` �.�' 1..._7 L,G Signature of officeadministering oath Printed name of officer administering oath Title of officer administering oath Forms provided by Texas Ethics Commission www.ethics.state.tx.us Varsinn V1 _r1_R4944 CERTIFICATE OF INTERESTED PARTIES FORM 1295 1 of 1 Complete Nos. 1- 4 and 6 if there are interested parties. Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties. OFFICE USE ONLY CERTIFICATION OF FILING Certificate Number: 2016-15311 Date Filed: 02/18/2016 Date Acknowledged: 02/23/2016 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Austin Traffic Signal Const. Co, Inc. Pflugerville, TX United States 2 Name of governmental entity or state agency that is a party to the contract for which the form is being filed. City of Round Rock 3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the goods or services to be provided under the contract. Avery Nelson -CR 112- AW Grimes Traffic Signal - Signage - Lighting installation 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling Intermediary 5 Check only if there is NO Interested Party. ❑ X 6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct. Signature of authorized agent of contracting business entity AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me, by the said this the day of 20 , to certify which, witness my hand and seal of office. Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.34944