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Home My WebLink AboutCORRESPONDENCE - RFP - 8847 CURED-IN-PLACE PIP SANITARY SEWERS/ STORMWATER MAINS REHABILITATION (2)Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 FORT COLLINS UTILITIES CONSTRUCTION WORK ORDER 2019-2020 CURED-IN-PLACE PIPE LINING WORK ORDER NO. UC+L2019-01 CONTRACTOR: C & L Water Solutions Page 1 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 TABLE OF CONTENTS AGREEMENT FORMS 00525 Work Order, Notice of Award & Bid Schedule 00530 Work Order Notice to Proceed 00600 Bonds and Certificates 00610 Performance Bond 00615 Payment Bond 00630 Certificate of Insurance 00635 Certificate of Substantial Completion 00640 Certificate of Final Acceptance 00650 Lien Waiver Release (CONTRACTOR) 00651 Lien Waiver Release (SUBCONTRACTOR) 00660 Consent of Surety 00670 Application for Exemption Certificate 00800 Supplementary Conditions 00900 Addenda, Modifications and Payment 00950 Work Order Change Order Form 00960 Application for Payment ADDITIONAL DOCUMENTS Attachment A DRAWING INDEX Page 2 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00500 CONSTRUCTION WORK ORDER AGREEMENT FORMS 00525 Work Order, Notice of Award & Bid Schedule 00530 Work Order Notice to Proceed Page 3 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00525 WORK ORDER, NOTICE OF AWARD AND BID SCHEDULE TO: UC & L Water Solutions WORK ORDER NUMBER: UC+L2019-01 PROJECT TITLE: U2019 Cured-in-Place Pipe lining ORIGINAL BID/RFP NUMBER & NAME: U8847 Cured-in-Place Pipe MASTER AGREEMENT EFFECTIVE DATE: UOctober 14, 2019 ARCHITECT/ENGINEER: UNA OWNER’S REPRESENTATIVE: URay Fisher WORK ORDER COMPLETION DATE: UMay 30, 2020 MAXIMUM FEE: (time and reimbursable direct costs): $ U636,064.00 NOTICE OF AWARD DATE: UNovember 25, 2019 OWNER: UCity of Fort CollinsU (hereinafter referred to as OWNER) 1. WORK. Pursuant to your MASTER AGREEMENT with OWNER dated UOctober 14, 2019U, and your Work Order Proposal dated UAugust 27, 2019,U you have been awarded a Work Order for U2019 Cured-in-Place Pipe liningU. PROJECT DESCRIPTION & SITE LOCATION: USee attached documentation. 2. CONTRACT PRICE, BONDS AND CERTIFICATES. The price of your Work Order is Usix hundred thirty-six thousand sixty-four dollars and zero centsU ($U636,064.00U). Pursuant to the AGREEMENT and the Work Order Documents, Performance and Payment Bonds and insurance are required. 3. CONTRACT TIMES. Pursuant to the MASTER AGREEMENT and the Work Order Documents, the date for Substantial Completion of this Work Order is UApril 30, 2020U, and after Substantial Completion, the date for Final Completion is UMay 30, 2020U. 4. LIQUIDATED DAMAGES. OWNER and CONTRACTOR recognize that time is of the essence of this Work Order and that OWNER will suffer financial loss if the Work is not completed within the times specified in paragraph 3 above, plus any extensions thereof allowed in accordance with Article 12 of the General Conditions. They also recognize the delays, expenses and difficulties involved in proving in a legal proceeding the actual loss suffered by OWNER if the Work is not completed on time. Accordingly instead of requiring any such proof, OWNER and CONTRACTOR agree that as liquidated damages for delay (but not as penalty) CONTACTOR shall pay OWNER the amounts set forth hereafter. 1) Substantial Completion: Ufive hundred dollarsU ($U500.00U) for each calendar day or fraction thereof after UApril 30, 2020U until the work is Substantially Complete. 2) Final Acceptance: After Substantial Completion, Utwo hundred dollarsU ($U200.000U) for each calendar day or fraction thereof after U30 calendar daysU until the Work is ready for Final Payment and Acceptance. Page 4 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 5. PAYMENT PROCEDURES. CONTRACTOR shall submit Applications for Payment in accordance with Article 14 of the General Conditions. Applications for Payment will be processed by OWNER. PROGRESS PAYMENTS. OWNER shall make progress payments on account of the Contract Price on the basis of CONTRACTOR's Application for Payment, once each month during construction as provided below. All progress payments will be on the basis of the progress of the Work measured by the schedule of values established in paragraph 2.6 of the General Conditions and in the case of Unit Price Work based on the number of units completed, and in accordance with the General Requirements concerning Unit Price Work. Prior to Substantial Completion, Owner will be entitled to withhold as contract retainage five percent (5%) of each progress payment, but, in each case, less the aggregate of payments previously made and less such amounts as OWNER may withhold, in accordance with paragraph 14.7 of the General Conditions. If, in the sole discretion of Owner, Owner determines that the character and progress of the Work have been satisfactory to OWNER, OWNER may determine that as long as the character and progress of the Work remain satisfactory to them, there will be no additional retainage on account of Work completed in which case the remaining progress payments prior to Substantial Completion will be in an amount equal to 100% of the Work completed. 95% of materials and equipment not incorporated in the Work (but delivered, suitably stored and accompanied by documentation satisfactory to OWNER as provided in paragraph 14.2 of the General Conditions) may be included in the application Section 00960. Upon Substantial Completion payment will be made in an amount sufficient, if necessary, to increase total payments to CONTRACTOR to 95% of the Contract Price, less such amounts as OWNER may withhold in accordance with paragraph 14.7 of the General Conditions or as provided by law. Upon Final Completion and Acceptance of the Work in accordance with paragraph 14.13 of the General Conditions, OWNER shall pay the remainder of the Contract Price as provided in said paragraph 14.13. 6. EXECUTION. Work Order Documents must be executed in DocuSign within fifteen (15) calendar days of the date of this Notice of Award. Contractor shall attach Payment and Performance Bonds and Certificate of Insurance(COI) to the Work Order Documents in DocuSign. In addition, one original set of executed Bonds and COI shall be provided to the Buyer. Failure to comply with these conditions within the time specified will entitle OWNER to consider your Work Order Proposal abandoned and to annul this Work Order & Notice of Award. Page 5 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 UCONTRACTOR’S NOTICE OF AWARD REPRESENTATION & EXECUTIONU: CONTRACTOR agrees to perform the services identified above, in accordance with the terms and conditions contained herein, the MASTER AGREEMENT, and the NOTICE OF AWARD between the parties. In the event of a conflict between or ambiguity in the terms of the MASTER AGREEMENT or specific Work Orders, the MASTER AGREEMENT shall control. CONTRACTOR: C & L Water Solutions By: Date: Name: Title: Page 6 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Chris Larson Chief Operations Officer December 9, 2019 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 OWNER’S ACCEPTANCE & EXECUTION: This Work Order and the attached Documents are hereby accepted and incorporated herein by this reference. ACCEPTANCE: Date: Ray Fisher, Manager, Collection Operations REVIEWED: Date: Pat Johnson, Senior Buyer REQUISITION ENTERED BY: Date: ACCEPTANCE: Date: Sandra Bratlie, Special Projects Manager, Utilities Distribution Systems ACCEPTANCE: Date: Andrew Gingerich, Director, Water Field Operations ACCEPTANCE: Date: Theresa Connor, Deputy Director, Water Engineering & Field Services ACCEPTANCE: Date: Kevin Gertig, Utilities Executive Director (if greater than $1,000,000) ACCEPTANCE: Date: Gerry Paul, Purchasing Director (if greater than $60,000) ACCEPTANCE: Date: Darin Atteberry, City Manager (if greater than $1,000,000) ATTEST: Date: City Clerk (if greater than $1,000,000) Page 7 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F 12/2/19 Melissa Walker Coordinator, Finance December 9, 2019 December 9, 2019 December 9, 2019 December 9, 2019 December 9, 2019 December 9, 2019 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 BID SCHEDULE Page 8 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Scope of Work U2019 CIPP Lining Segments Descriptions 100 Blk. Harvard (easement) 650’ of 6” VCP 12 services M10029612 to M10027516 100 Blk. Harvard (easement) 135’ of 6” VCP no services M10027516 to M10027157 2200 Blk. Vassar (easement) 499’ of 6” VCP 12 services M10026629 to M10026628 2200 Blk. Loyola (easement) 511’ of 6” VCP 12 services M10029599 to M10028837 Total 6” VCP 1,795’ 36 Tap Reinstatements 5 Intruding Taps Traffic Control 6” VCP $1,577.00 4220 W CO RD 54G 399’ of 8” VCP no services M10030841 to M10034723 4200 White Lane 193’ of 8” VCP 1 service M10030840 to M10030839 3501 MCconnell Drive 152’ of 8” VCP 2 services M10025174 to M10028109 Flag Drive & Post Road 217’ 0f 8” VCP 3 services M10034627 to M10028111 3601 Post Road 386’ of 8” VCP 10 services M10028116 to M10028115 3000 Blk. N Overland Trail 235’ of 8” VCP 3 services M10033718 to M10025183 2924 Schaeffer Drive 277’ of 8” VCP 2 services M10028147 to M10027724 3513 Vernon Drive 154’ of 8” VCP 1 service M10028181 to M10033348 3500 Vernon Drive 235’ of 8” VCP 7 services M10028182 to M10028181 2223 N Overland Trail 396’ of 8” VCP 6 services M10025190 to M10028186 1425 N Taft Hill Road (easement) 170’ of 8” VCP no services M10028002 to M10032586 1427 N Taft Hill Road (easement) 78’ of 8” VCP 1 service M10032586 to M10033963 1429 N Taft Hill Road (easement) 189’ of 8” VCP no services M10033963 to M10024695 Tree Line Place (easement) 303’ of 8” VCP 4 services Stub to M10029501 426 W Willox Lane (easement) 335’ of 8” VCP 5 services M10029501 to M10029508 415 W Willox Lane (easement) 353’ of 8” VCP 6 services M10029508 to M10029502 2019 CIPP Line Segments Page 2 Page 9 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Scope of Work 2704 W Vine Drive (easement) 377’ of 8” VCP 4 services M10033679 to M10025160 2100 Trevor Street 278’ of 8” VCP 7 services M10028202 to M10028204 712 Montview Road 263’ of 8” VCP 4 services M10028204 to M10028230 2916 Cherry Street 323’ of 8” VCP 4 services M10025171 to M10031393 533 Hollywood Street 407’ of 8” VCP 8 services M10034099 to M10034250 239 Hollywood Street 391’ of 8” VCP 8 services M10025163 to M10027708 525 Sunrise Lane 314’ of 8” VCP 7 services M10025367 to M10028214 697 N Impala Drive 393’ of 8” VCP 4 services M10025373 to M10025372 533 N Impala Drive 417’ of 8” VCP 10 services M10025372 to M10025371 513 N Impala Drive 40’ of 8” VCP 1 service M10025371 to M10033544 509 N Impala Drive 288’ of 8” VCP 10 services M10033544 to M10028219 1850 Laporte Avenue 172’ of 8” VCP 2 services M10028516 to M10027672 1115 Juniper Court 291’ of 8” VCP 4 services M10026073 to M10026272 430 N Lyons Street (easement) 233’ of 8” VCP no services M10028770 to M10033901 430 N Lyons Street (easement) 303’ of 8” VCP no services M10033901 to M10031211 1300 Blk. Elm Street 127’ of 8” VCP no services M10031211 to M10035069 1300 Blk. Elm Street 257’ of 8” VCP no services M10035069 to M10031210 1218 Elm Street 257’ of 8” VCP 3 services M10031210 to M10026047 1200 Elm Street 244’ of 8” VCP 3 services M10026047 to M10026084 1128 Elm. Street 114’ of 8” VCP no services M10026084 to M10026046 Elm & Hanna Street 414’ of 8” VCP 1 service M10026046 to M10026286 2019 CIPP Line Segments Page 3 Page 10 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Scope of Work Total 8” VCP 10,000’ 131 Tap Reinstatements 3 Intruding Taps Traffic Control 8” VCP $22,100.00 Page 11 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F QUANTITY UNIT UNIT PRICE TOTAL 1 1795 LF $76.00 $136,420.00 2 36 Ea $90.00 $3,240.00 3 5 Ea $125.00 $625.00 4 1 LS $1,577.00 $1,577.00 BID TOTAL $141,862.00 NOTES: Excludes any pipe which should not be lined due to a collapsed, offset or other physical defect condition which restricts the passage of equipment. Traffic Control: Price includes TCP, pickup/delivery, devices and necessary labor and equipment for control of traffic. DESCRIPTION 6 Inch UV CIPP Lining: Price includes 3mm UV Cured in Place Pipe Lining, bypass pumping, customer notifications, pre and post cctv and cleaning, testing and cleanup. Service Reinstatements: Price includes reinstatement of active service connections, measurement and brushing. Intruding Tap Removal: Price includes obstacle or intruding lateral trimming. _____________ _________ Proposal DATE: CUSTOMER NAME: ATTN: JOB NAME: 8-27-2019 City of Fort Collins Ray Fisher Sanitary Sewer Rehabilitation 2019 - 6" CIPP 12249 Mead Way, Littleton, CO 80125 1178 West 17th Street, Marriott-Slaterville, UT 84404 303.791.2521 phone 303.791.2524 fax 303.791.2521 phone 303.791.2524 fax Page 12 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F QUANTITY UNIT UNIT PRICE TOTAL 1 10000 LF $46.00 $460,000.00 2 131 Ea $90.00 $11,790.00 3 3 Ea $104.00 $312.00 4 1 LS $22,100.00 $22,100.00 BID TOTAL $494,202.00 NOTES: Proposal DATE: CUSTOMER NAME: ATTN: JOB NAME: 10-15-2019 City of Fort Collins Ray Fisher Sanitary Sewer Rehabilitation 2019 - 8" CIPP _____________ _________ Excludes any pipe which should not be lined due to a collapsed, offset or other physical defect condition which restricts the passage of equipment. Segment M10029501 to Cleanout: Manhole or access point must be utilized in lieu of the cleanout in order to complete CIPP. If an ccess point is preferred, C&L can excavate, install the CIPP and then reinstall a clean out once complete. This is not currently included in the pricing. Traffic Control: Price includes TCP, pickup/delivery, devices and necessary labor and equipment for control of traffic. DESCRIPTION 8 Inch UV CIPP Lining: Price includes 3mm UV Cured in Place Pipe Lining, bypass pumping, customer notifications, pre and post cctv and cleaning, testing and cleanup. Service Reinstatements: Price includes reinstatement of active service connections, measurement and brushing. Intruding Tap Removal: Price includes obstacle or intruding lateral trimming. 12249 Mead Way, Littleton, CO 80125 1178 West 17th Street, Marriott-Slaterville, UT 84404 303.791.2521 phone 303.791.2524 fax 303.791.2521 phone 303.791.2524 fax Page 13 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Schedule subject to change due to: - Weather delays - Traffic coordination Page 14 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00530 WORK ORDER NOTICE TO PROCEED NOTICE TO PROCEED DATE: November 25, 2019 WORK ORDER TITLE: 2019-2020 Cured-in-Place Pipe lining WORK ORDER NUMBER: C+L2019-01 TO: C & L Water Solutions Attn: This notice is to advise you: That the Work Order and all amendments and supplements to the Work Order Documents covering the above described Work have been fully executed by the CONTRACTOR and the OWNER. That the required CONTRACTOR's Performance and Payment Bonds and insurance have been received by the OWNER. That the OWNER has approved the said Work Order and Work Order Documents. Therefore, as the CONTRACTOR for the above described Work, you are hereby authorized and directed to proceed within ( ) calendar days from receipt of this notice as required by the Work Order and the AGREEMENT. The dates for Substantial Completion and Final Acceptance shall be , and , respectively. Dated this _____________ day of ___________, _____. CITY OF FORT COLLINS (OWNER) By: Name, Title ACKNOWLEDGMENT OF NOTICE Receipt of the above Work Order Notice to Proceed is hereby acknowledged this Day day of Month, Year. (CONTRACTOR) By: ___________________________________________ Name, Title Page 15 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00600 BONDS AND CERTIFICATES 00610 Performance Bond 00615 Payment Bond 00630 Certificate of Insurance 00635 Certificate of Substantial Completion 00640 Certificate of Final Acceptance 00650 Lien Waiver Release (CONTRACTOR) 00651 Lien Waiver Release (SUBCONTRACTOR) 00660 Consent of Surety 00670 Application for Exemption Certificate Page 16 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00610 PERFORMANCE BOND Bond No __ KNOW ALL MEN BY THESE PRESENTS: that C & L Water Solutions 122249 Mead Way Littleton, CO 80512 (an Individual), (a Partnership), (a Corporation), hereinafter referred to as the "Principal" and hereinafter referred to as "the Surety", are held and firmly bound unto City of Fort Collins, 300 LaPorte Ave, Fort Collins, Colorado 80522 a (Municipal Corporation) hereinafter referred to as the "OWNER", in the penal sum of ($ ) in lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, successors and assigns, jointly and severally, firmly by these presents. THE CONDITIONS OF THIS OBLIGATION are such that whereas the Principal entered into a certain Master Agreement with the OWNER, dated the 14P th P day, of October, 2019, a copy of which is hereto attached and made a part hereof, for the performance of The City of Fort Collins Work Order, titled 2019-2020 Cured-In-Place Pipe Lining, Work Order Number C+L2019-01, dated November 25, 2019, a copy of which is hereto attached and made a part hereof. NOW, THEREFORE, if the Principal shall well, truly and faithfully perform its duties, all the undertakings, covenants, terms, conditions and agreements of said Work Order and Master Agreement during the original term thereof, and any extensions thereof which may be granted by the OWNER, with or without Notice to the Surety and during the life of the guaranty period, and if the Principal shall satisfy all claims and demands incurred under such Work Order and Master Agreement, and shall fully indemnify and save harmless the OWNER from all cost and damages which it may suffer by reason of failure to do so, and shall reimburse and repay the OWNER all outlay and expense which the OWNER may incur in making good any default, then this obligation shall be void; otherwise to remain in full force and effect. PROVIDED, FURTHER, that the said Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Work Order and Master Agreement or to the Work to be performed thereunder or the Specifications accompanying the same shall in any way 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 Work Order and Master Agreement or to the Work or to the Specifications. PROVIDED, FURTHER, that no final settlement between the OWNER and the CONTRACTOR shall abridge the right of any beneficiary hereunder, whose claim may be unsatisfied. PROVIDED, FURTHER, that the Surety Company must be authorized to transact business in the State of Colorado and be acceptable to the OWNER. Page 17 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 IN WITNESS WHEREOF, this instrument is executed in three (3) counterparts, each one of which shall be deemed an original, this _____ day of ___________, _____. IN PRESENCE OF: Principal (Title) (Title) (Corporate Seal) (Address) IN PRESENCE OF: Other Partners _____________________________ By: _____________________________ By: IN PRESENCE OF: Surety _____________________________ By: _____________________________ (Address) (Surety Seal) NOTE: Date of Bond must not be prior to date of Work Order. If CONTRACTOR is Partnership, all partners should execute Bond. Page 18 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00615 PAYMENT BOND Bond No __ KNOW ALL MEN BY THESE PRESENTS: that C & L Water Solutions 122249 Mead Way Littleton, CO 80512 (an Individual), (a Partnership), (a Corporation), hereinafter referred to as the "Principal" and hereinafter referred to as "the Surety", are held and firmly bound unto City of Fort Collins, 300 LaPorte Ave, Fort Collins, Colorado 80522 a (Municipal Corporation) hereinafter referred to as the "OWNER", in the penal sum of ($ ) in lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, successors and assigns, jointly and severally, firmly by these presents. THE CONDITIONS OF THIS OBLIGATION are such that whereas the Principal entered into a certain Master Agreement with the OWNER, dated the 14P th P day, of October, 2019, a copy of which is hereto attached and made a part hereof, for the performance of The City of Fort Collins Work Order, titled 2019-2020 Cured-In-Place Pipe Lining, Work Order Number C+L2019-01, dated November 25, 2019, a copy of which is hereto attached and made a part hereof. NOW, THEREFORE, if the Principal shall make payment to all persons, firms, subcontractors, and corporations furnishing materials for or performing labor in the prosecution of the Work provided for in such Work Order and Master Agreement and any authorized extension or modification thereof, including all amounts due for materials, lubricants, repairs on machinery, equipment and tools, consumed, rented or used in connection with the construction of such Work, and all insurance premiums on said Work, and for all labor, performed in such Work whether by subcontractor or otherwise, then this obligation shall be void; otherwise to remain in full force and effect. PROVIDED, FURTHER, that the said Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Work Order and Master Agreement or to the Work to be performed thereunder or the Specifications accompanying the same shall in any way 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 Work Order and Master Agreement or to the Work or to the Specifications. PROVIDED, FURTHER, that no final settlement between the OWNER and the CONTRACTOR shall abridge the right of any beneficiary hereunder, whose claim may be unsatisfied. PROVIDED, FURTHER, that the Surety Company must be authorized to transact business in the State of Colorado and be acceptable to the OWNER. Page 19 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 IN WITNESS WHEREOF, this instrument is executed in three (3) counterparts, each one of which shall be deemed an original, this _____ day of ___________, _____. IN PRESENCE OF: Principal (Title) (Title) (Corporate Seal) (Address) IN PRESENCE OF: Other Partners _____________________________ By: _____________________________ By: IN PRESENCE OF: Surety _____________________________ By: _____________________________ (Address) (Surety Seal) NOTE: Date of Bond must not be prior to date of Work Order. If CONTRACTOR is Partnership, all partners should execute Bond. Page 20 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00630 CERTIFICATE OF INSURANCE CONTRACTOR shall submit Certificate of Insurance in compliance with the Work Order Documents. Page 21 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00635 CERTIFICATE OF SUBSTANTIAL COMPLETION TO: CITY OF FORT COLLINS (OWNER) PROJECT TITLE: 2019-2020 Cured-In- Place Pipe Lining DATE OF SUBSTANTIAL COMPLETION: LOCATION: Fort Collins, Colorado OWNER: City of Fort Collins PROJECT OR SPECIFIED PART SHALL CONTRACTOR: C & L Water Solutions INCLUDE: WORK ORDER DATE: November 25, 2019 The Work performed under this Work Order, pursuant to the Work Order Documents, has been inspected by authorized representatives of the OWNER, CONTRACTOR, and the ENGINEER and the project (or specified part of the project, as indicated above) is hereby declared to be substantially completed on the above date. A tentative list of items to be completed or corrected is appended hereto. This list may not be exhaustive, and the failure to include an item on it does not alter the responsibility of the CONTRACTOR to complete all the Work in accordance with the Work Order Documents. _____________________________ By: __________________________ ________ PROJECT MANAGER AUTHORIZED REPRESENTATIVE DATE The CONTRACTOR accepts the above Certificate of Substantial Completion and agrees to complete and correct the items on the tentative list within the time indicated. _____________________________ By: __________________________ ________ CONTRACTOR AUTHORIZED REPRESENTATIVE DATE The OWNER accepts the project or specified area of the project as substantially complete and will assume full possession of the project or specified area of the project at 12:01 a.m., on . The responsibility for heat, utilities, security, and insurance under the Work Order Documents shall be as set forth under "Remarks" below. CITY OF FORT COLLINS ________ By: __________________________ ________ OWNER AUTHORIZED REPRESENTATIVE DATE REMARKS: _________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Page 22 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00640 CERTIFICATE OF FINAL ACCEPTANCE DATE: TO: C & L Water Solutions 122249 Mead Way Littleton, CO 80512 You are hereby notified that on the Day day of Month, Year, the City of Fort Collins, Colorado, has accepted the Work completed by Contractor Company Name, for the City of Fort Collins Work Order, titled Project Title, Work Order Number PM's Tracking #. Your continuing obligations and guarantees for the Project will be as provided in the Work Order and Work Order Documents. Sincerely, City of Fort Collins OWNER By: ___________________________________________ ___________________________________________ Name, Title Page 23 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00650 LIEN WAIVER RELEASE (CONTRACTOR) TO: City of Fort Collins, Colorado (OWNER) FROM: C & L Water Solutions WORK ORDER TITLE: 2019-2020 Cured-In-Place Pipe Lining WORK ORDER NUMBER: C+L2019-01 1. The CONTRACTOR acknowledges having received payment, except retainage from the OWNER for all work, labor, skill and material furnished, delivered and performed by the CONTRACTOR for the OWNER or for anyone in the construction, design, improvement, alteration, addition or repair of the above described project. 2. In consideration of such payment and other good and valuable consideration, the receipt and adequacy of which are hereby acknowledged, the CONTRACTOR voluntarily waives all rights, claims and liens, including but not limited to, mechanic's liens, Miller Act claims (40 U.S.C.A. 270 a and b), stop notices, equitable liens and labor and material bond rights which the CONTRACTOR may now or may afterward have, claim or assert for all and any work, labor, skill or materials furnished, delivered or performed for the construction, design, improvement, alteration, addition or repair of the above described project, against the OWNER or its officers, agents, employees or assigns, against any fund of or in the possession or control of the OWNER, against the project or against all land and the buildings on and appurtenances to the land improved by the project. 3. The CONTRACTOR affirms that all work, labor and materials, furnished, delivered or performed to or for the construction, design, improvement, alteration, addition or repair of the project were furnished, delivered or performed by the CONTRACTOR or its agents, employees, and servants, or by and through the CONTRACTOR by various Subcontractors or materialmen or their agents, employees and servants and further affirms the same have been paid in full and have released in full any and all existing or possible future mechanic's liens or rights or claims against the project or any funds in the OWNER'S possession or control concerning the project or against the OWNER or its officers, agents, employees or assigns arising out of the project. 4. The CONTRACTOR agrees to defend and hold harmless the OWNER, the lender, if any, and the Surety on the project against and from any claim hereinafter made by the CONTRACTOR's Subcontractors, materialmen, employees, servants, agents or assigns against the project or against the OWNER or its officers, employees, agents or assigns arising out of the project for all loss, damage and costs, including reasonable attorneys fees, incurred as a result of such claims. 5. The parties acknowledge that the description of the project set forth above constitutes an adequate description of the property and improvements to which this Lien Waiver Release pertains. It is further acknowledged that this Lien Waiver Release is for the benefit of and may be relied upon by the OWNER, the lender, if any, and Surety on any labor and material bonds for the project. Page 24 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 Signed this ______ day of __________, ___. CONTRACTOR: Company Name By: ___________________________________________ ___________________________________________ Name, Title ATTEST: _____________________________ Secretary STATE OF COLORADO ) )ss. COUNTY OF LARIMER ) Subscribed and sworn to before me this _________ day of __________, _____, by ________________________________________________________________. Witness my hand and official seal. My Commission Expires: ___________________________. _________________________ Notary Public Page 25 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00650 LIEN WAIVER RELEASE (SUBCONTRACTOR) TO: City of Fort Collins, Colorado (OWNER) FROM: C & L Water Solutions (CONTRACTOR) WORK ORDER TITLE: 2019-2020 Cured-In-Place Pipe Lining WORK ORDER NUMBER: C+L2019-01 1. The Subcontractor acknowledges having received payment from the CONTRACTOR for all work, labor, skill and material furnished, delivered and performed by the Subcontractor for the CONTRACTOR or for anyone in the construction, design, improvement, alteration, addition or repair of the above described project. 2. In consideration of such payment and other good and valuable consideration, the receipt and adequacy of which are hereby acknowledged, the Subcontractor voluntarily waives all rights, claims and liens, including but not limited to, mechanic's liens, Miller Act claims (40 U.S.C.A. 270 a and b), stop notices, equitable liens and labor and material bond rights which the Subcontractor may now or may afterward have, claim or assert for all and any work, labor, skill or materials furnished, delivered or performed for the construction, design, improvement, alteration, addition or repair of the above described project, against the CONTRACTOR or its officers, agents, employees or assigns, against the project or against all land and the buildings on and appurtenances to the land improved by the project. 3. The Subcontractor affirms that all work, labor and materials, furnished, delivered or performed to or for the construction, design, improvement, alteration, addition or repair of the project were furnished, delivered or performed by the Subcontractor or its agents, employees, and servants, or by and through the Subcontractor by various sub- subcontractors or materialmen or their agents, employees and servants, and further affirms the same have been paid in full and have released in full any and all existing or possible future mechanic's liens or rights or claims against the project or against the CONTRACTOR or its officers, agents, employees or assigns arising out of the project. 4. The Subcontractor agrees to defend and hold harmless the CONTRACTOR, the lender, if any, and the Surety on the project against and from any claim hereinafter made by the Subcontractor's sub-subcontractors, materialmen, employees, servants, agents or assigns against the project or against the CONTRACTOR or OWNER, lender or Surety or their officers, employees, agents or assigns arising out of the project for all loss, damage and costs, including reasonable attorneys fees, incurred as a result of such claims. 5. The parties acknowledge that the description of the project set forth above constitutes an adequate description of the property and improvements to which this Lien Waiver Release pertains. It is further acknowledged that this Lien Waiver Release is for the benefit of and may be relied upon by the CONTRACTOR, OWNER, the lender, if any, and Surety on any labor and material bonds for the project. Page 26 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 Signed this ______ day of _________, ___. SUBCONTRACTOR: By: ___________________________________________ ___________________________________________ Name, Title ATTEST: _____________________________ Secretary STATE OF COLORADO ) )ss. COUNTY OF LARIMER ) Subscribed and sworn to before me this _________ day of __________, _____, by __________________________________________________________________. Witness my hand and official seal. My Commission Expires: ___________________________. __________________________________ Notary Public Page 27 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00660 CONSENT OF SURETY TO: City of Fort Collins, Colorado (hereinafter referred to as the "OWNER") CONTRACTOR: C & L Water Solutions TITLE: 2019-2020 Cured-In-Place Pipe Lining WORK ORDER NUMBER: C+L2019-01 WORK ORDER DATE: November 25, 2019 In accordance with the provisions of the Work Order and Master Agreement between the OWNER and the CONTRACTOR as indicated above, for the Work Order titled 2019-2020 Cured-In-Place Pipe Lining on bond of , (Surety) _______________________________________ hereby approves of the Final Payment to the CONTRACTOR, and agrees that Final Payment to the CONTRACTOR shall not relieve the Surety Company of any of its obligations to the OWNER, as set forth in the said Surety Company's Bond. IN WITNESS WHEREOF, the Surety Company has hereunto set its hand this _________ day of _________ _, _____. ____________________________________________ (Surety Company) By: ________________________________________ (Name) Attorney-in-Fact ATTACH: Power of Attorney and Certificate of Authority of Attorney(s)-in-Fact. Page 28 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 Page 29 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 Page 30 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00800 SUPPLEMENTARY CONDITIONS These Supplementary Conditions amend or supplement the General Conditions of the Construction Contract (EJCDC General Conditions 1910-8, 1990 edition, with City of Fort Collins Modifications, Rev. 9/94) and other provisions of the Work Order Documents as indicated below. SC-1 DEFINITIONS SC-1.38. Add the following language to the conclusion of paragraph 1.38 of the General Conditions: 1.38. Substantial Completion. .... Substantial Completion is further defined as that degree of completion of the operating facilities or systems of the Project defined in the Work Order sufficient to provide the OWNER the full time, uninterrupted, continuous, beneficial operation of the modifications, and all inspections required have been completed and identified conditions corrected. SC-1.43.A. Add the following new paragraph immediately after paragraph 1.43 of the General Conditions: 1.43.A. Work Order--A written document executed by OWNER and CONTRACTOR that provides for the construction of the Work, or a portion of the Work pursuant to the Master Agreement and all as required by the Work Order Documents, and that becomes a Work Order Document when executed. SC-2 PRELIMINARY MATTERS SC-2.8. Delete paragraph 2.8 of the General Conditions entirely and replace it with the following paragraph: 2.8. Preconstruction Conference. Within ten days after the Work Order Times for a Work Order start to run, but before any Work at the site is started, a conference attended by CONTRACTOR, ENGINEER and others as appropriate will be held to establish a working relationship among the parties as to the Work and to discuss the schedules referred to in paragraph 2.6, procedures for handling Shop Drawings and other submittals, processing Applications for Payment, and maintaining required records. SC-2.10. Add the following new paragraph immediately after paragraph 2.9 of the General Conditions: 2.10. Work Order Required for All Work. References to the Master Agreement in this Article 2 and in the General and Supplementary Conditions and Work Order Documents notwithstanding, no Work shall be initiated or performed until CONTRACTOR has received a signed and executed Work Order, and the Notice to Proceed, from OWNER; and no provision of this Article 2 or of the General and Supplementary Conditions and Work Order Documents shall permit or require any action of CONTRACTOR in the absence of a signed and executed Work Order. All provisions of this Article 2 and of the General and Supplementary Conditions and Work Page 31 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 Order Documents referencing the Master Agreement or other parts of the Work Order Documents, or permitting or requiring any action of CONTRACTOR, shall be read as referencing and, as appropriate, requiring a signed and executed Work Order. SC-4 AVAILABILITY OF LANDS; SUBSURFACE AND PHYSICAL CONDITIONS; REFERENCE POINTS SC-4.2.1.2. Add the following new paragraph immediately following paragraph 4.2.1.2 of the General Conditions: 4.2.1.2.1. No drawing of physical conditions in or relating to existing surface or subsurface structures (except Underground Facilities referred to in paragraph 4.3) which are at or contiguous to the site have been utilized by the Engineer in preparation of the Work Order Documents, except the following: None SC-5 BONDS AND INSURANCE SC-5.4.7. Include the following parties or entities as additional insureds, as provided in paragraph 5.4.7 of the General Conditions: 5.4.7.1. City of Fort Collins, Colorado, PO Box 580, Fort Collins, CO 80522. 5.4.7.2. NA SC-5.4.8.1. Add the following new paragraph immediately following paragraph 5.4.8 of the General Conditions: 6.4.8.1. Limits of Liability. The limits of liability for the insurance required by the paragraph numbers of the General Conditions listed below are as follows: For Paragraphs 5.02.A.1 and 5.02.A.2: Coverage A - Statutory Limits; Coverage B - $100,000 / $100,000 / $500,000. For Paragraphs 5.02.A.3 and 5.02.A.5: The Commercial General Liability policy will have limits of $1,000,000 combined single limits (CSL). This policy will include coverage for Explosion, Collapse, and Underground coverage unless waived by the Owner. For Paragraph 5.02.A.6: The Comprehensive Automobile Liability Insurance policy will have limits of $1,000,000 combined single limits (CSL). For Paragraph 5.02.B.3: This policy will include completed operations coverage / product liability coverage with limits of $1,000,000 combined single limits (CSL). This policy shall also include an Umbrella Excess Liability as follows: General liability and automobile liability insurance in an amount not less than $1,000,000 per occurrence in excess of the above stated primary limits. Page 32 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SC-6 CONTRACTOR’S RESPONSIBILITIES SC-6.14.3. Add the following new paragraph immediately after paragraph 6.14.2 of the General Conditions: 6.14.3. The following Laws or Regulations are included in the Work Order Documents as mandated by statute or for the convenience of the CONTRACTOR. Other Laws and Regulations apply which are not included herein, and are within the CONTRACTOR's duty and responsibility for compliance thereto: 6.14.3.1. Notice to owners of Underground Facilities is required prior to excavations in the vicinity of such facilities. 6.14.3.2. Unless otherwise decided by reason of the amount of the Work Order Price involved, or other good reason, before or at the time that the contract is awarded to a corporation outside the State of Colorado, such corporation must carry out the proper procedure to become authorized to do business in the State of Colorado, designate a place of business therein, and appoint an agent for service of process. Such corporation must furnish the OWNER with a certificate from the Secretary of State of Colorado has been issued by its office and there shall also be procured from the Colorado Secretary of State or certified copy of the designated of place of business and appointment of agent for service of process, or a letter from the Colorado Secretary of State that such designation of place of business and agent for service of process have been made. 6.14.3.3. The CONTRACTOR must conform to the rules and regulations of the Industrial Commission of Colorado. Particular reference is made to rules and regulations governing excavation Work adopted by the Industrial Commission of Colorado. SC-11 CHANGE OF CONTRACT PRICE SC-11.6.2.7. Add the following new paragraph to paragraph 11.6.2 of the General Conditions: 11.6.2.7. Cost of the Work. Allowances for profit, overhead and mark-up prescribed by the Master Agreement shall be used in lieu of any CONTRACTOR'S fee, overhead, profit or mark-up allowances as prescribed in paragraphs 11.6.2.1, 11.6.2.2, and 11.6.2.3. SC-12 CHANGE OF CONTRACT TIMES SC-12.3. Add the following language to the end of paragraph 12.3 of the General Conditions: 12.3. .... Lost days due to abnormal weather conditions will be allocated as required. SC-14 PAYMENTS TO CONTRACTOR AND COMPLETION SC-14.1. Add the following language to the end of paragraph 14.1 of the General Conditions: Page 33 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 14.1. Schedule of Values. .... Progress payments on the fixed fee shall be in proportion to the cumulative actual Cost of the Work as a percentage of the Allowable Cost of the Work. An amount not to exceed fifteen (15%) percent of the fixed fee shall be advanced to the Contractor for mobilization in the first progress payment. Page 34 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00900 ADDENDA, MODIFICATIONS AND PAYMENT 00950 Change Order 00960 Application for Payment Page 35 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00950 CHANGE ORDER NO. PROJECT TITLE: 2019-2020 Cured-In-Place Pipe Lining CONTRACTOR: C & L Water Solutions WORK ORDER NUMBER: C+L2019-01 PO NUMBER: DESCRIPTION: 1. Reason for Change: Why is the change required? 2. Description of Change: Provide description of the changes to the Work 3. Change in Work Order Price: 4. Change in Work Order Time: ORIGINAL WORK ORDER PRICE $ .00 TOTAL APPROVED CHANGE ORDER .00 TOTAL PENDING CHANGE ORDER .00 TOTAL THIS CHANGE ORDER .00 TOTAL % OF THIS CHANGE ORDER % TOTAL C.O.% OF ORIGINAL WORK ORDER % ADJUSTED WORK ORDER COST $ .00 CONTRACTOR: Company Name By: Date: Name: Title: ACCEPTED: Date: City PM Name, Title REVIEWED: Date: Name, Buyer or Senior Buyer ACCEPTED: Date: Name, Title ACCEPTED: Date: Gerry Paul, Purchasing Director (if greater than $60,000) Page 36 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00960 APPLICATION FOR PAYMENT PROJECT Page 1 of 1 OWNER: ENGINEERS: ADDRESS: NUMBER DATE AMOUNT $ - $ - $ - NUMBER DATE AMOUNT FUND OBJECT Amount Due this Pay Application (before retainage): $ - $ - 0.00% Payment of the above Amount Due This Application has been reviewed by the OWNER'S Project Manager BY: DATE: DATE: NAME & TITLE: BY: DATE: NAME & TITLE: Official Purchasing Form Last updated 10/2017 Net Change by Change Order: Change order %: Original Contract Amount Net Change by Change Order Revised Current Contract Amount Total Work Completed to Date: Total Stored to Date: CHANGE ORDERS PAY APPLICATION Application is made for Payment as shown below in connection with the Contract. The present status of the account for this Contract is as follows: CONTRACTOR: $ - $ - RETAINAGE $ -NumbersCharge $ - $ - Less Previous Payments: Total Completed and Stored Materials to Date: Less Retainage $ - $ - $ - AMOUNT DUE THIS APPLICATION: $ - The above Amount Due this Application is requested by the CONTRACTOR's Project Manager. BY: PO NUMBER ADDRESS: ADDRESS: APPLICATION NUMBER APPLICATION DATE PERIOD BEGINNING PERIOD ENDING PROJECT NUMBER Retainage to Date: NAME & TITLE: Total (after retainage): Payment of the above Amount Due This Application is approved by the OWNER. Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 Unit Price Total Quanitity Total Quantity Total Quantity Total 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 $ - $ - $ - $ - $ - 0.00% $ - $ - $ - $ - $ - 0.00% Official Purchasing Form Last Updated 10/2017 Total to Date Less Retention Change Orders to Date (see attached) $ - $ - CONTRACT SUMMARY Total Due Adjusted Contract Amount $ - Total Change Order Work to Date (see attached) Value of Work in Place Percent Complete Including Stored Materials Less Retention @ 10% up to 50% complete, 5% beyond 50% of Adjusted Contract Crosscheck Total Completed to Date Total Materials Remaining @ Site $ - $ - $ - Original Contract Amount Less Previous Billings $ - $ - $ - $ - Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 ATTACHMENT A DRAWING INDEX WORK ORDER #C+L2019-01 WORK ORDER TITLE: 2019-2020 Cured-In-Place Pipe Lining BY: NA Sheet Title Drawing Revision Date Page 39 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F $ - $ - Combined Total Completed to Date Total Contract Amount Total This Period Previous Billings Balance Remaining Percent Complete PAY REQUEST Item # Description Quantity Cost Remaining Percent UOMComplete Contract Summary This Period Previous Total to Date Period Ending: Page 38 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F The undersigned CONTRACTOR certifies that all obligations of CONTRACTOR incurred in connection with the WORK have been satisfied as required in paragraph 14.3 of the General Conditions of the Contract. CERTIFICATION BU SCOPE OF WORK CHANGE ORDERS RECONCILIATION CHANGE ORDERS INVOICE NUMBER Total Change Order Work to Date: $ - $ - Retainage Previous: Change in Retainage: Page 37 of 39 DocuSign Envelope ID: E679EFF1-80B3-41DD-9123-0B41CEEDD94F