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Contract - John King Construction - 10/27/2016 City of Round Rock, Texas Contract Forms Standard Form of Agreement for Competitive Sealed Proposal: Section 00500 City of Round Rock, Texas Standard Form of Agreement between o,,Owner and Contractor IliAGREEMENT made as of the kC441 1 b ���� (� )day of8e4ei38r in the year 2016. BETWEEN the Owner: City of Round Rock,Texas(hereafter"Owner"or"City") 221 East Main Street Round Rock, Texas 78664 and the Contractor John King Construction,Ltd. ("Contractor") 1220 McNeil Road,Suite 300A Round Rock,TX 78681 The Project is described as: Construction of Fireball Grill at Dell Diamond,located at 3400 East Palm Valley Boulevard,Round Rock,Texas. The Architect is: R.Gill&Associates 100 Bunny Run Lane,#100 Horseshoe Bay Texas 78657 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 Page 1 of 6 Standard Form of Agreement 00366047/ss2 1 I ARTICLE 3 DATE OF COMMENCEMENT;DATE OF SUBSTANTIAL COMPLETION; DATE OF FINAL COMPLETION 3.1 The date of commencement of the Work shall be the date of this Agreement unless a different date is stated below or provision is made for the date to be fixed in a Notice to Proceed issued by Owner. 3.2 The Contract Time shall be measured from the date delineated in the Notice to Proceed. 3.3 Contractor shall commence Work within ten (10) calendar days from the date delineated in the Notice to Proceed. 3.4 Contractor shall achieve Substantial Completion of the entire Work no later than March 6,2017,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 ($1,000.00) for each calendar day that Substantial Completion is delayed after the date(s)specified for Substantial Completion. It is hereby agreed that the liquidated damages to which g Owner is entitled hereunder are a reasonable forecast of 'ust compensation for the harm r that would be caused by Contractor's failure to achieve Substantial Completion of the Work(or any portion thereof) on or before the date(s)specified for Substantial Completion in the Agreement. It is agreed that the harm that would be caused by such failure, which includes loss of expected use of the Project areas, provision of alternative storage hl' facilities and rescheduling of moving and occupancy dates, is one that is incapable or very difficult of accurate estimation.It is hereby agreed that if Substantial Completion of the Work(or any portion thereof)is not achieved on or before thirty(30) days after the date(s) specified for Substantial Completion in the Agreement, the Owner shall have the option to either collect liquidated damages as set forth herein or to thereafter rely on its remedies under the Contract Documents and at law and in equity, including without limitation, the recovery of actual damages. The date(s) specified for Substantial Completion of the Work (or any portion thereof) in the Agreement shall be subject to adjustment as provided in the Contract Documents. 3.6 Contractor shall achieve Final Completion of the entire Work no later than April 1,2017. ARTICLE 4 CONTRACT SUM 4.1 Owner shall pay Contractor the Contract Sum in current funds for Contractor's performance of the Contract. The Contract Sum shall be Eight Hundred Twenty-Two Thousand Eight and no/100 Dollars 822 ($ ,008.00),subject to additions and deductions as provided in the Contract Documents. 4.2 The Contract Sum is based upon the following alternates which are described in the Contract Documents and are hereby accepted by Owner: I, Accepted Alternates and Post Proposal Modifications attached as Addendum #1 SII . 1111 ARTICLE 5 PAYMENTS 5.1 PROGRESS PAYMENTS 5.1.1 Based upon Applications for Payment submitted to Architect and Owner by Contractor,and Certificates for Payment issued by Architect and not disputed by Owner and/or Owner's lender, Owner shall make progress it Page 2 of 6 e I 111 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 Architect and Owner, and Architect 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 Architect and Owner after the application date fixed above,payment shall be made by Owner not later than one month after the Architect 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 Architect and Owner may require. This schedule,unless objected to by Architect 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 fmal payment;and .2 a final Certificate for Payment has been issued by Architect. 5.2.2 Owner's final payment to Contractor shall be made no later than thirty (30) days after the issuance of Architect'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. 6.2 The Work may be suspended by Owner as provided in Article 15 of the City of Round Rock General Conditions. Page 3 of 6 Ili il;'j! J1 1 „il ARTICLE 7 ENUMERATION OF CONTRACT DOCUMENTS � 7.1 The Contract Documents, except for Modifications issued after execution of this Agreement, are ;;i enumerated as follows: 7.1.1 The Agreement is this executed version of the City of Round Rock, Texas Standard Form of Agreement 1 between Owner and Contractor for Competitive Sealed Proposals,as modified. � ;i 7.1.2 The General Conditions are the "City of Round Rock Contract Forms 00700," General Conditions, as 11�l modified. I 7.1.3 The Supplementary, Special, and other Conditions of the Contract are those contained in the Project 1 Manual dated October 27,2016. ¢';' 7.1.4 The Specifications are those contained in the Project Manual dated October 27,2016. 1111 7.1.5 The Drawings,if any,are those contained in the Project Manual dated October 27,2016. 1 ill 1 7.1.6 The Insurance&Construction Bond Forms of the Contract are those contained in the Project Manual dated fil' iil' October 27,2016. ,Ii, 7.1.7 The Notice to Bidders,Instructions to Bidders,Bid Form, and Addenda,if any,are those contained in the ' Project Manual dated October 27,2016. 11 1 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. ii 1 7.1.9 Other documents,if any,forming part of the Contract Documents are as follows: Accepted Alternates and Post-Proposal Modifications attached as Addendum#1 I, ARTICLE 8 MISCELLANEOUS PROVISIONS iII' I 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: Travis Wilkes Building Construction Manager,General Services 212 Commerce Boulevard Round Rock,TX 78664 I 8.3 Contractor's representative is: John King John King Construction,Ltd. 1220 McNeil Road,Suite 300A . Round Rock,Texas 78681 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. Ii' I Page 4 of 6 it i. � 1. 1111 �I. 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 I the extent funds are not available. This Agreement is a commitment of City of Round Rock's current revenues only. IG I' 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. 11 8.9 Both parties hereby expressly agree that no claims or disputes between the parties arising out of or relating I 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. ;'I 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. p i ISI • [Signatures on the following page.] 1,1 tt • 11 Ali ' I Iii 111 j; ,1 Page 5 of 6 ji�'• ' VI 111 II I MThis 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 Architect for use in the administration of the I Contract,and the remainder to Owner. 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 Architect for use in the administration of the Contract,and the remainder to Owner. fOWNER CONTRACTOR CITY OF UND ROCK,TE S JOHN KING CONSTRUCTION,LTD. Printed Name: O �-' "` kApNaNPrinted . a dV)I() N• N lin AANOV-- 'Pa—1C s 1 Title v�v 1 Title: Pr'€s 1 e + Date Signed: 1 I t© • Ro Date Signed: JO . 2 I • 2-4 I ATTEST: 4SrA41/ . 1664244 City Clerk FOR .I Y,APPROVED S TO FORM: 116141111' ' L ---d_L__ City A j.rney i ii iii Page 6 of 6 I1 I, ii ADDENDUM#1 POST-PROPOSAL NEGOTIATED ITEMS Herein are the changes to scope and pricing resulting from post proposal negotiated modifications for the Fireball Grill Project at Dell Diamond, in Round Rock,Williamson County, Texas. A. This Addendum#1 containing the Post-Proposal Negotiated Items shall be considered part of the Standard Form Agreement and Contract Documents for the above-referenced Project. Where provisions of the following supplementary data conflict with those in any other of the Contract Documents,this Addendum#1 shall govern and take precedence. B. John King Construction, Ltd. (the "Contractor") shall make all necessary adjustments set forth this Addendum #1. This document shall be attached to the Standard Form Agreement as an Exhibit and included in the Construction Project Manual as part of the Construction Documents. C. The Original Proposal Amount was $893,087,000.00 which included the base bid in the amount of$583,498; alternate #1 in the amount of$232,431, alternate #2 in the amount $60,607, and I II alternate#3 in the amount of$16,551. The agreed upon alternates and/or scope modifications are as follows and as attached on pages two(2) and fourteen (14)of this Addendum: I II 1. City ACCEPTS alternate #1 (modified from the original proposal as described in this l document) in the amount of$197,353.00. City ACCEPTS Alternate #2 (modified from the original proposal as described in this document) in the amount of$25,167.00. The City does NOT accept alternate#3. 2. Express to preform demolition of existing temporary walls and temporary electric - reduced original base bid$3,338. II 3. Clarified standing seam roof-increased original base bid$5,007. 4. Removed stained concrete from base bid-reduced original base bid$17,802. 5. Remove earthwork from base bid-reduced original base bid$2,688. 6. Value engineered stone fence for trex fence- deducted$15,926 from original alternate#1 masonry. 7. Added trex fence to original alternate#1 -increased original alternate#1 $8,829. 8. Ventilation hoods were in original alternate#1 -vent hoods moved to base bid,alternate #2 adjusted to one Ston ac unit and vent hood makeup air system—increased$32,129 to original base bid. 9. Alternate#3 not accepted. 11' 11 it D. The Final Negotiated Amount is $822,008.00 which includes the base bid in the amount of $599,488.00; alternate #1 in the amount of $197,353.00 and alternate #2 in the amount $25,167.00 for a Net Savings from Original Proposed Amount of$71,079.00. r1 'IJ Bond No.TXC608491 TEXAS STATUTORY PERFORMANCE BOND (PUBLIC WORKS) KNOW ALL MEN BY THESE PRESENTS:That John King Construction (hereinafter called the Principal),as Principal,and Merchants Bonding Company(Mutual) a corporation organized and existing under the laws of the State Iowa licensed to do business in the State of Texas and admitted to write bonds,as surety(hereinafter called the Surety),are held and firmly bound unto City of Round Rock (hereinafter called the Obligee),in the amount of Eight Hundred Twenty Two Thousand Eight And 00/100 (Dollars), . ( $822,008.00 for thea p yment whereof,the said Principal and Surety bind themselves,and their heirs,administrators executors,successors,and assigns,jointly and severally, firmly by these presents: WHEREAS,the Principal has entered into a certain contract with the Obligee,dated the l (�'- day of ,for Construction of Fireball Grill at Dell Diamond which contract is hereby referred to and made a part hereof as fully and to the same extent as if copied at length herein. NOW,THEREFORE,THE CONDITION OF THIS OBLIGATION IS SUCH,That if the said Principal shall faithfully p perform the work in accordance with the plans, specifications and contract documents, then this obligation shall be null and void; otherwise to remain in full force and effect; PROVIDED, HOWEVER, that this bond is executed pursuant to the provisions of Chapter 2253 of the Texas Government Code and all liabilities on this bond shall be determined in accordance with the provisions, conditions and limitations of said Chapter to the same extent as if it were copied at length herein. IN WITNESS WHEREOF,the said Principal and Surety have signed and sealed this instrument this day of I ATTEST: PRINCIPAL: John King Construction By: By: , l Vi III li LSURETY: Merchants Bonding Company(Mutual)APPROVED AS TO FORM: By: By: Justin MCQuain,Attorney-in-Fact H Obligee , 0 Bond No.TXC608491 I TEXAS STATUTORY PAYMENT BOND (PUBLIC WORKS) IKNOW ALL MEN BY THESE PRESENTS: That John King Construction (hereinafter called the Principal),as Principal, and Merchants Bonding Company(Mutual) IIa corporation organized and existing under the laws of the State of ,Iowa do business in the State of Texas and admitted to write bonds,as surety(hereinafter called the Suret licedsed to y),are held and firmly bound unto City of Round Rock 111 (hereinafter called the Obligee), in the amount of Eight Hundred Twenty Two Thousand Eight And 00/100 I ($ $822,008.00 for the a (Dollars), p yment whereof,the said Principal and Surety bind themselves,and their heirs,administrators, executors,successors,and assigns,jointly and severally,firmly by these presents: III WHE AS the Principal has entered intoe a fccertain contract with the Obligee,dated the `O vU��o ,for day of Construction of Fireball Grill at Dell Diamond which contract is hereby referred to and made a part hereof as fully and to the same extent as if copied at length herein. NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, That if the said Principal shall pay all claimants I supplying labor and material to him or a subcontractor in the prosecution of the work provided for in said contract, then this obligation shall be null and void; otherwise to remain in full force and effect; wPROVIDED, HOWEVER, that this bond is executed pursuant to the provisions of Code and all liabilities on this bond shall be determined in accordance with the provisions, conditions and limitations or 2253 of ff said ChapterTexastto the same extent as if it were copied at length herein 0 IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this instrument this day of II I ATTEST: PRINCIPAL: John King Construction II By: By: .. �/�l.-- 1-'7. I SURETY: Merchants Bonding Company(Mutual) I APPROVED AS TO FORM: By: -1• BY Justin McQuain,Attorney-in-fact IObligee . I ______—.....,„40 JOHNK-2 OP ID:SK ,4`CORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/07/2016 J THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONT PRODUCER NAMEACT Eileen Wallace,ACSR Brown&Brown of Austin PHONE 512-343-0000 FAX No):512-346-1736 3301 Northland Dr.,Suite 301 (A/C,No,Ext): Austin,TX 78731 E-MAIL Alfred Jamison DeBellas SS:ewallace@bbinsaustin.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Valley Forge Insurance Co 20508 I INSURED John King Construction Ltd INSURER B:Continental Casualty Company 20443 1220 McNeil Rd#300 Round Rock,TX 78681 INSURER C I INSURERINSURER ED:: 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 I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY FIAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBERPOLICY EFF POLICY EXP (MM/DD/YYYY) (MM/DDIYWY) LIMITS I A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS-MADE X OCCUR 6043086911 10/22/2016 10/22/2017 DAMAGE TO RENTED PREMISES(Ea occurrence) _ $ 100,000 MED EXP(Any one person) _ $ 15,000 PERSONAL&ADV INJURY _ $ 1,000,000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JERCOT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ IAUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A X ANY AUTO C6043086925 10/22/2016 10/22/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE 6043086939 10/22/2016 10/22/2017 AGGREGATE $ 5,000,000 IDED X RETENTION$ 10000 $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY X STATUTE EOR H A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 6043367557 10/22/2016 10/22/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 I If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Equipment Floater 6043086911 10/22/2016 10/22/2017 Leas/Ren 130,000 A Builders Risk C6043333442 10/22/2016 10/22/2017 Per Loc 12,500,000 IDESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) - RE:Fireball Grill Dell Diamond Project I I -CERTIFICATE HOLDER CANCELLATION CITYRRI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I City of Round Rock THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: City Manager 221 East Main Street AUTHORIZED REPRESENTATIVE Round Rock,TX 78664 �� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I 0 b o a ct F ,pry N m e� o � tW 4 m m t�A W 2 N ro E m b a 0 0 C C d O O @ E �c to H u, a vii u�i YS b a N O h: E � rd o w a m Or O ro E � a a � zs b w a c 0 0 ro m h N m a co M ca R0 m � w w b O Z N W o m a a NN N V C V 9 b Q O O r r LU N Z O — 4 m m 0 to - 1p y U, u� F U °' 0 1- -- E U O U ani a Q A W N 5 O U D OJ 8 c 0. CD C 0 Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.277 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: 2016-120305 Date Filed: 10/05/2016 Date Acknowledged: 10/18/2016 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. John Kign Construction, Ltd. Round Rock, 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 services, goods, or other property to be provided under the contract. Fireball Grill Dell Diamond General Construction 4 Name of Interested Party City, State, Country (place of business) Nature of interest (check applicable) Controlling I Intermediary 5 Check only if there is NO Interested Party. 1771 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 V1.0.277 Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.277 CERTIFICATE E OF HNITEREST ED PAR`S S FORM 1295 lofl 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: 2016-120305 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. John Kign Construction, Ltd, Round Rock, TX United States ; Date Filed: 10/05/2016 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 services, goods, or other property to be provided under the contract. Fireball Grill Dell Diamond General Construction 4 Name of Interested Parry City, State, Country (place of business) Nature of interest (check applicable) Controlling I Intermediary 5 Check only it there is NO Interested Party. X 6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct. o`.•�v rU�� Cynthia L Hempel My Commilssion Expires 04/2912016 �! r Signature ofauQgent of contracting business entity AFFIX NC?TAftY Sf �I�P l S�L ABO Sworn to and subscribed before me, by the said 'i 1t' 7 L ,this the day of ; 20 it., 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 V1.0.277