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Contract - Patin Construction - 9/22/2016 I City of Round Rock. Texas Contract Forms Standard Form of •,greementt: Section ©f5Of IICity of Round Rock, Texas Standard Form of Agreement between QOwner and Contractor AGREEMENT made as of the-}' 14 X11 j)y of r U 'i(7-1 in the year 20 (io. U BETWEEN the Owner: City of Round Rock,Texas(hereafter"Owner"or"City") 221 East Main Street Round Rock,Texas 78664 and the Contractor Patin Construction LLC ("Contractor") 3800 W.2nd Street I Taylor,TX 76574 The Project is described as: IGreenlawn Storm Drainage Improvements I The Engineer is: City of Round Rock I 2008 Enterprise Drive Round Rock,TX 78664 For and in consideration of the mutual terms, conditions and covenants of this Agreement and all I accompanying documents between Owner and Contractor, the receipt and sufficiency of which are hereby acknowledged,Owner and Contractor agree as follows: I Ai'TICLE i THE CONTI'ACT DOCUMENTS IThe Contract Documents consist ofthis Agreement,Conditions of the Contract(General,Supplementary and ronditions), 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 I 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. IARTICLE 2 THE WORK OF THIS CONTRACT Contractor shall fully execute the Work described in the Contract Documents,except to the extent specifically I indicated in the Contract Documents to be the responsibility of others. I 00500 4-2016 Page 1 of 5 Standard Form of Agreement 00307791 I 1<!g—011.--'1. 92_ I r ARTICLE 3 DATE OF COMMENCEMENT; DATE OF SU STANTIAL COMPLETllON; DATE OF FINAL COMPLETION 3.1 The date of commencement of the Work shall be the date of this Agreement unless a different date is stated below or provision is made for the date to be fixed in a Notice to Proceed issued by Owner. 3.2 The Contract Time shall be measured from the date delineated in the Notice to Proceed. 3.3 Contractor shall commence Work within seven (7 ) calendar days from the date delineated in the Notice to Proceed. 3.4 Contractor shall achieve Substantial Completion of the items of Work listed on Attachment A to this Agreement no later than ninety (90 )calendar days from issuance by Owner of Notice to Proceed, and Contractor shall achieve Substantial Completion of the entire Work no later than one hundred five (105 )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($ 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 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 I 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 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 Contract. The Contract Sum shall be Two hundred sixty-three thousand seventy-nine and no/100 dollars I ($$263,079.00 ),subject to additions and deductions as provided in the Contract Documents. 4.2 Does the Contract Sum include alternates which are described in the Bid Form? No X , Yes .Ifes,please provide details below: �I 00500 4-2016 Page 2 of 5 Standard Form of Agreement 00307791 • ARTICLE 5 PAYMENTS 5.1 PROGRESS PAYMENTS 5.1.1 Based upon Applications for Payment submitted to Engineer and Owner by Contractor,and Certificates for Payment issued by Engineer and not disputed by Owner and/or Owner's lender,Owner shallmake 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. r5.1.4 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. I5.2.2 Owner's final payment to Contractor shall be made no later than thirty (30) days after the issuance of Engineer's final Certificate for Payment. In no event shall final payment be required to be made prior to thirty(30) days after all Work on the Contract has been fully performed,Defects in the Work discovered prior to final payment shall be treated as non-conforming Work and shall be corrected by Contractor prior to final payment,and shall not be treated as warranty items, ARTICLE 6 TERMINATION OR SUSPENSION 6.1 The Contract may be terminated by Owner or Contractor as provided in Article 15 of the City of Round Rock General Conditions. 00500 4-2016 Page 3 of 5 Standard Form of Agreement 00307791 1 I 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 CONT, ACT 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 August 2016 7.1.4 The Specifications are those contained in the Project Manual dated August 2016 7.1.5 The Drawings, if any,are those contained in.the Project Manual dated August 2016 7.1.6 The Insurance&Construction Bond Forms of the Contract are those contained in the Project Manual dated August 2016 7.1.7 The Notice to Bidders,Instructions to Bidders,Bid Form,and Addenda, if any,are those contained in the Project Manual dated August 2016 [I 7.1.8 If this Agreement covers construction involving federal funds, thereby requiring inclusion of mandated contract clauses, suchfederally 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: A 44-'eh v' Y 4- 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 Iprovision as amended or supplemented by other provisions of the Contract Documents. 8.2 Owner's representative is: Danny Malden,P.E,,City Engineer 2008 Enterprise Drive Round Rock,TX 78664 dhalden(aroundrocktexas.gov(512)218-6610 8.3 Contractor's representative is: Tim Patin 3800 W.2nd Street Taylor,TX 76574 Tim@patincon.com(512)269 1071 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. I 00500 4,2016 00307791 Page 4 of 5 Standard Form of Agreement ! 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. I8.7 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 fmore strongly for nor against either party. I 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 II I Williamson County, Texas. This Agreement shall be governed by and construed in accordance with the laws and court decisions of the State of Texas. II l 8.9 Both parties hereby expressly agree that no claims or disputes between the parties arising out of or relating 1 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. This Agreement is entered into as of the day and year first written above and is executed in at least three(3) I I original copies, of which one is to be delivered to Contractor, one to Engineer for use in the administration of the I Contract,and the remainder to Owner. 1 I OWNER CONTRACTOR CITYO r i UNP ROCK,TE S Patin Construction LAe I _ Printed Name: 'O14 I v , a / � Printed Name: 1��� � � _ , Title ��I�,N Title: !`.re-s-,�1 c",,./ I / Date Signed: I L2 Z `o Date Signed: l'--1l3 6" ATTEST: 1 I 49141/1 -'1/ . City Clerk f FOR C TY APPROVED A' TO FORM: ICity Atte] ey I I 00500 4-2016 00307791 Page 5 of 5 Standard Form of Agreement I ( 1 r L. Ti - PERFORMANCE BOND BOND NO.: 70136779 THE STATE OF TEXAS § 1 1 , COUNTY OF WILLIAMSON § § KNOW ALL BY THESE PRESENTS: That , C'onstn tion LLC of the City of Taylor , Countyrof I[11 Williamson , and State of Texas , as Principal, and USA GuaranteeThe Company of North menta 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 Ll Two Hundred Sixty Three Thousand Seventy-nine Dollars and No Cents Dollars ($ 763 079 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,... . ertain written Agreement with the Owner dated the -- _ day of L g �. �iz 20 6 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 ILj herein consisting of Greenlawn Storm Drainage.Improvements (Name of the Project) IL, 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 r observe and perform all and singular the covenants, conditions and agreements in and by said 1 L 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 I, I 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 L 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; IiPROVIDED,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 i I lengthternr p accordance with the provisions of said Chapter 2253 to the same extent as if it were copied at herein., �� i Li tl P 00610 7.2009 Page 1 P, 00090656 Performance Bond LI 11 ( 11 • L. PERFORMANCE BOND NS (continued) (- Surety, for value received, stipulates and agrees that no change, extension of time, alteration or IL_ 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 Iaddition to the terms of the Agreement, or to the work to be performed thereunder. r1 IN WITNESS WHEREOF, the said Principal and Surety have signed and sealed this instrument ii this . ..,__.29th .. day of September 20.16 . r1 It- Patin Construction, LLC Prxncx The Guarantee Company of North America USA -� .- • Surety J / e- .•' -) Ce, tKenneth Nitsche Printed Name Printed Name , 1 By: Titles e2 ..e- .1,-- Title: _ •• r•• -In-Fact Address: 3$00 W. 2nd Street Ada -ss: One Towne Square, Suite 1470 _l j Taylor, TX 76574 Snnthfie1c, Michigan 48076 Ili_ IiiResident Agent o urety: n /A- - Signa e Keeth Nitsche Printed Name 143 E. Austin . Street Address Giddings, TX 78942 ill] City, State&Zip Code �J . ] 11 t_1 L Page 2 00610 7-2009 Performance Bond U 00090656 ( l 11. Fl IL PAYMENT BOND BOND NO. 70136779 THE STATE OF TEXAS 1 , § § KNOW ALL MEN BY THESE PRESENTS; IL COUNTY OF WILLIAMSON r1I That Patin Construction, LLC , of the City of TaylorCoun y of Williamson , and State of Texas as Principal, and NW1146,4aarairaLISApany of authorized under the laws of the State of Texas to act as Surety on Bonds for Principals, are held (l and firmly bound unto THE CITY OF ROUND ROCK, (OWNER), and all subcontractors, I workers, laborers, mechanics and.suppliers as their interest may appear, all of whom shall have the right to sue upon this bond, in the penal sum of 11[_] Two Hundred Sixty Three Thousand Seventy-nine Dollars and No Cents Dollars ($ 263,079.00 ) for the payment whereof, well and truly be made the IL said Principal and Surety bind themselves and their heirs, administrators, executors, successors, and assigns,jointly and severally,by these presents: rl WHEREAS, the P 'ncipal has entered into a certain written Agreement with the Owner, dated � the day of D LaP�(L ' , 20 li, , to which Agreement is hereby referred to and made a part hereof as fully and to the same extent as if copied at length r herein consisting of: Greenlawn Storm Drainage Improvements 1 ]11- j (Name of the Project); iii 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, 11, then this obligation shall be and become null and void; otherwise to remain in full force and ri effect. :_iPROVIDED,HOWEVER,that this bond is executed pursuant to the provisions of Chapter 2253, l Texas Government code, as amended, and all liabilities on this bond shall be determined in J accordance with the provisions of said Chapter 2253 to the same extent as if it were copied at length herein. . I Page 1 00620 7-2009 Payment Bond 00090656 ,_l i [.1 I ri ri) PAYMENT BOND (continued) 1 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, n 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 tie contract,or to the work to be performed thereunder, 1. J IN WITNESS WHEREOF, the said Principal and Suretyhave signed and sealed this Instrument this 29th day of September , 20 6 I[li Patin Construction,LLC �.. The Guarantee Company of North America USA Iri Principal K � Surety i:- , �z-7 _ Kenneth Nitsche Painted Name Panted Name I rJ IBy: l ` 2 Ey� ,..kTitle: 'axF,l.�y Title: • .me -In-Fact L l Address: 3800 W.2nd Street Address: One Towne Square,Suite 1470 Taylor,TX 76574 Southfield,Michigan 48076 r IResident Agent ' urety: i -.-. . ISignat a e Kenneth Nitsche Printed Name IL 143 E.Austin • Street Addressidd f_� Gings,TX 78942 LI _ t-. I 11 _ f ii00620 7 Page 2 00090656 Payment Bond 1 — - I Client#:46421 PATINCON ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/28/2016 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACTNAME: Carla West The Nitsche Group PHONE FAX (A/C,No,Ext):979-540-2208 (A/C,No): 143 East Austin MAASS: thenitsche rou com Giddings,TX 78942-3299 ADDRESS: @ 9 P• 979 542-3666 INSURER(S)AFFORDING COVERAGE NAIL# INSURERA:Cincinnati Insurance Company 10677 INSURED INSURER B:RSUI Indemnity Company 22314 Patin Construction LLC INSURER C:Texas Mutual Insurance Company 22945 3800 W.2nd Street Cincinnati Insurance Company10677 Taylor,TX 76574 INSURER D: I 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 I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE TYPE OF INSURANCE INSRL SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY EPP0166349 10/25/2013 10/25/2016 EACH OCCURRENCE $1,000,000 • X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $10,000 X PD Ded:2,000 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X JECT PRO LOC $ D AUTOMOBILE LIABILITY EBA0166349 10/25/2015 10/25/2016Ea COMBaccidINEDent)SI $NGLE LIMIT 1,000,000 ( X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) XDrive Oth Car $ A X UMBRELLA LIAB X OCCUR EPP0166349 10/25/2013 10/25/2016 EACH OCCURRENCE $5,000,000 B X EXCESS LIAB X CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$0 $ C WORKERS COMPENSATION 0001212733 06/03/2016 06/03/2017X O STATU- OTH- AND EMPLOYERS'LIABILITY TTORY LIMITS ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B Excess Umbrella NHA074949 02/29/2016 10/25/2016 $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Project: Greenlawn Storm Drainage Improvements As per policy provision, Certificate Holder is listed as additional insured in regard to the auto and general liability policies as provided by blanket additional insured endorsement when required by written contract.General liability,auto and workers compensation policies include(s)a 30 Days Notice of Cancellation endorsement providing 30 days advance notice if policy is canceled by the company other than for nonpayment of premium,or direct cancellation by named insured as per policy provision. CERTIFICATE HOLDER CANCELLATION City of Round Rock,Texas SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 221 E.Main St. ACCORDANCE WITH THE POLICY PROVISIONS. Round Rock,TX 78664 _ AUTHORIZED REPRESENTATIVE # . Z ..,.a-4,X•.t-- ACORD 25(2010/05 ©1988-2010 ACORD CORPORATION.All rights reserved. ) 1 of 1 The ACORD name and logo are registered marks of ACORD #S665654/M646356 066 CERTIFICATE OF INTERESTED PARTIES FORD 1295 10f1 Complete Nos. 1- d 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. 2016-110471 Patin Construction LLC Taylor, TX United States Date Filed: 09/12/2016 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. Greenlawn Storm Drainage 2016 Greenlawn Storm Drainage Improvements 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. ❑ X 6 AFFIDAVIT I swear, or affirm, under penal f-pmpry tha�-the above disclosure is true and correct. "p VICTORtABRANNON ,�---�'�'-- _* ;*= My Notary ID # 125118111} Expires November 15, 2020 Signature of a thorized agent of contracting business entity AFFIX NOTARY STAMP / SEAL ABOVE V111^� Sworn t and subscribed before me, by the said i Y ,/1 I i(.[ � this the 20, to certify which, witness my hand and seal of office. day of III �gaz�,I J r ign ure of officer Wministering oath Printed name of officer administering oath tle of officer administer' g oath Forms provided by Texas Ethics Commission www.ethics.state.tx.us version v:>_.u.z r r Forms provided by Texas Ethics Commission www.ethics.state.tx.us version V1.0.21 / CERTIFICATE OF INTERESTED PARTIES FORM 3.295 10f1 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: 2016-110471 Date Filed: 09/12/2016 Date Acknowledged: 09/12/2016 1 Name of business entity filing form, and the city, state and country of the business entity's place of business. Patin Construction LLC Taylor, 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. Greenlawn Storm Drainage 2016 Greenlawn Storm Drainage Improvements 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. ❑ 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. 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