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CORRESPONDENCE - RFP - 8286 CONSTRUCTION CONTRACTOR FOR PROJECTS AT THE WATER & WASTEWATER TREATMENT FACILITIES (59)
Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 FORT COLLINS UTILITIES CONSTRUCTION WORK ORDER WTF SITE WORK – PAVING & GRADING WORK ORDER NO. SCP-HYDROWTFSW050918 CONTRACTOR: Hydro Construction, Inc Page 1 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00525 WORK ORDER, NOTICE OF AWARD AND BID SCHEDULE TO: Hydro Construction, Inc. WORK ORDER NUMBER: SCP-HydroWTFSW050918 PROJECT TITLE: WTF Site Work – Paving & Grading ORIGINAL BID/RFP NUMBER & NAME: 8286, Construction Contractor for Projects at the Water & Wastewater Treatment Facilities, Award Date MASTER AGREEMENT EFFECTIVE DATE: June 20, 2016 ARCHITECT/ENGINEER: NA OWNER’S REPRESENTATIVE: Sue Paquette WORK ORDER COMMENCEMENT DATE: May 21, 2018 WORK ORDER COMPLETION DATE: November 1, 2018 MAXIMUM FEE: (time and reimbursable direct costs): $123,401.00 NOTICE OF AWARD DATE: May 9, 2018 OWNER: City of Fort Collins (hereinafter referred to as OWNER) 1. WORK. Pursuant to your MASTER AGREEMENT with OWNER dated June 20, 2016, and your Work Order Proposal dated May 3, 2018, you have been awarded a Work Order for WTF Site Work – Paving & Grading. PROJECT DESCRIPTION & SITE LOCATION: Contractor to provide construction assistance and services to conduct site work at the Fort Collins Water Treatment Facility (WTF). Services shall include repaving and grading area around the WTF. See the attached supporting documentation. 2. CONTRACT PRICE, BONDS AND CERTIFICATES. The price of your Work Order is one hundred twenty-three thousand four hundred one dollar and zero cents ($123,401.00). 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 November 1, 2018, and after Substantial Completion, the date for Final Completion is January 1, 2019. 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 Page 4 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 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: five hundred dollars ($500.00) for each calendar day or fraction thereof after November 1, 2018 until the work is Substantially Complete. 2) Final Acceptance: After Substantial Completion, two hundred dollars ($200.00) for each calendar day or fraction thereof after 60 calendar day period until the Work is ready for Final Payment and Acceptance. 5. 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. CONTRACTOR’S NOTICE OF AWARD REPRESENTATION & EXECUTION: 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: Hydro Construction, Inc. By: Date: Name: Title: Page 5 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 May 15, 2018 Jim Eurich COO 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: Sue Paquette, Special Project Manager REVIEWED: Date: Pat Johnson, Senior Buyer APPROVED AS TO FORM: Date: Name,City Attorney's Title (if greater than $1,000,000) ACCEPTANCE: Date: Mark Kempton, Water Production Division Manager ACCEPTANCE: Date: Owen L. Randall, Water Systems Engineering Division Manager ACCEPTANCE: Date: Carol Webb, Water Resources & Treatment Operations Manager 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 6 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 May 17, 2018 May 15, 2018 May 17, 2018 May 18, 2018 May 18, 2018 May 18, 2018 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 BID SCHEDULE Page 7 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 May 3, 2018 Hydro Construction Company, Inc. - Scope of Services. Fort Collins Water Treatment Facility-Site Paving and Grading Provide assistance and efforts to remove existing paving, replace paving and regrade various areas on the plant site. Cost of Work $123,401.00 • Administration Entrance and Parking Area Remove existing paving, add additional road base and geogrid as necessary and replace paving (~400 sy). • Horsetooth Dissipater Area Remove existing gravel, place road base, install concrete ribbon curb, concrete paving and place asphalt roadway (~30 tons). • Filter Gallery Access Road Remove existing paving, add additional road base and geogrid as necessary, clean and grade at culvert outlet and replace paving (~80 sy). • T5/T6 Roof Drains and Slope Install concrete curbs at roof drain outlets (2 locations), repair, regrade and place fabric and rip rap at culvert outlets then re-seed slope. • Maintenance Shop Parking Area Remove existing paving, add additional road base as necessary and replace paving (~17 sy). Work will commence after issuance of signed work order, with a substantial completion date of November 1, 2018 and final completion date of December 31, 2018. Page 8 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Standard Estimate Report Page 1 FCWTF Paving & Site Gradi 5/3/2018 11:56 AM Project name FCWTF Paving & Site Gradi Labor rate table Labor - Bare Equipment rate table Equipment Report format Sorted by 'Structure/Group phase' 'Detail' summary Allocate addons Page 9 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Standard Estimate Report Page 2 FCWTF Paving & Site Gradi 5/3/2018 11:56 AM Item Description Takeoff Qty Labor Amount Material Amount Subcontract Amount Name Equipment Amount Other Amount Total Amount 01 Gen Cond 1000.000 GENERAL CONDITIONS 26 Bonds 1.00 ls - - - 2,221 2,221 14 Project Manager 5.00 wk 9,940 - - 1,250 190 11,380 14 Superintendent 5.00 wk 9,940 - - 1,250 408 11,598 12 Office Trailer 1.25 mo - - - 204 204 18 Telephone Charges 1.25 mo - - - 163 163 20 Temporary Toilets 1.25 mo - - - 163 163 10 Safety 1.00 ls 1,136 - 1,000 - 544 2,680 16 Conex 1.25 mo - - - 1,500 0 1,500 GENERAL CONDITIONS 21,016 1,000 4,000 3,892 29,908 440.00 Labor hours 400.00 Equipment hours 1900.000 OWNED EQUIPMENT 10 Gators 1.00 mo - - - 1,000 - 1,000 OWNED EQUIPMENT 1,000 1,000 01 Gen Cond 21,016 0 1,000 5,000 3,892 30,908 440.00 Labor hours 400.00 Equipment hours 02 Admin Area 2000.000 SITEWORK 20 Demo Paving 1.00 ls 716 - 750 489 1,955 10 Crushed Gravel -Roads 30.00 cy 358 745 - 560 - 1,663 20 Geogrid 600.00 sf 179 652 - - 196 1,027 15 Asph Paving 402.00 sy - - 32,400 - - 32,400 SITEWORK 1,252 1,398 32,400 1,310 685 37,045 18.00 Labor hours 8.00 Equipment hours 02 Admin Area 1,252 1,398 32,400 1,310 685 37,045 18.00 Labor hours 8.00 Equipment hours 03 HTD Area 2000.000 SITEWORK 20 Remove Tracking Pad 1.00 ls 537 - 950 82 1,568 10 Crushed Gravel -Roads 21.00 cy 250 522 - 392 - 1,164 15 Asph Paving 65.00 sy - - 5,239 - - 5,239 4 Concrete Paving 6" 1.00 ls 1,431 272 - 720 27 2,450 4 Concrete Curbs 1.00 ls 1,431 1,071 - 400 92 2,994 Page 10 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Standard Estimate Report Page 3 FCWTF Paving & Site Gradi 5/3/2018 11:56 AM Item Description Takeoff Qty Labor Amount Material Amount Subcontract Amount Name Equipment Amount Other Amount Total Amount SITEWORK 3,650 1,864 5,239 2,462 201 13,416 155.60 Labor hours 37.60 Equipment hours 03 HTD Area 3,650 1,864 5,239 2,462 201 13,416 155.60 Labor hours 37.60 Equipment hours 04 FG Area 2000.000 SITEWORK 20 Demo Paving 1.00 ls 537 - 750 489 1,776 10 Crushed Gravel -Roads 4.00 cy 48 99 - 75 - 222 20 Geogrid 150.00 sf 45 163 - - 49 257 10 Culvert Cleaning 1.00 ls 153 0 - 40 - 193 10 Culvert Rip Rap 1.00 ls 307 103 - 160 - 570 15 Asph Paving 80.00 sy - - 6,448 - - 6,448 SITEWORK 1,089 366 6,448 1,025 538 9,465 26.77 Labor hours 7.07 Equipment hours 04 FG Area 1,089 366 6,448 1,025 538 9,465 26.77 Labor hours 7.07 Equipment hours 05 T5/T6 Area 2000.000 SITEWORK 20 Install Rebar Dowels 1.00 ls 1,159 - 175 272 1,606 20 Erosion Control 1.00 ls 613 201 - 50 71 935 10 Culvert Repair/Regrade 1.00 ls 613 - 160 - 773 10 Culvert Rip Rap 1.00 ls 460 103 - 240 - 803 10 Precast Type C Inlet 1.00 ls 1,738 1,283 - 720 82 3,822 4 Concrete Curbs 1.00 ls 1,431 1,250 - 400 60 3,141 -sub Sub - Landscaping 1.00 ls - - 2,500 - - 2,500 SITEWORK 6,015 2,837 2,500 1,745 484 13,581 194.40 Labor hours 48.00 Equipment hours 7000.000 THERMAL & MOIST PROTECT -sub Sub - Exterior Caulking 1.00 ls - - 1,500 - - 1,500 THERMAL & MOIST PROTECT 1,500 1,500 05 T5/T6 Area 6,015 2,837 4,000 1,745 484 15,081 194.40 Labor hours 48.00 Equipment hours 06 MS Area Page 11 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Standard Estimate Report Page 4 FCWTF Paving & Site Gradi 5/3/2018 11:56 AM Item Description Takeoff Qty Labor Amount Material Amount Subcontract Amount Name Equipment Amount Other Amount Total Amount 2000.000 SITEWORK 20 Demo Paving 1.00 ls 537 - 750 489 1,776 10 Crushed Gravel -Roads 4.00 cy 2 39 - 6 - 46 15 Asph Paving 24.00 sy - - 1,934 - - 1,934 SITEWORK 538 39 1,934 756 489 3,756 6.085 Labor hours 0.09 Equipment hours 7000.000 THERMAL & MOIST PROTECT -sub Sub - Exterior Caulking 1.00 ls - - 1,500 - - 1,500 THERMAL & MOIST PROTECT 1,500 1,500 06 MS Area 538 39 3,434 756 489 5,256 6.085 Labor hours 0.09 Equipment hours Page 12 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Standard Estimate Report Page 5 FCWTF Paving & Site Gradi 5/3/2018 11:56 AM Estimate Totals Description Amount Totals Hours Rate Cost Basis Cost per Unit Percent of Total Labor 33,561 840.847 hrs 27.20% Material 6,503 5.27% Subcontract 52,521 42.56% Equipment 12,298 500.750 hrs 9.97% Other 6,289 5.10% 111,172 111,172 90.09 90.09% Profit & Overhead 12,229 11.000 % T 9.91% 12,229 123,401 9.91 100.00% Total 123,401 Page 13 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00530 WORK ORDER NOTICE TO PROCEED NOTICE TO PROCEED DATE: WORK ORDER TITLE: WTF Site Work – Paving & Grading WORK ORDER NUMBER: SCP-HydroWTFSW050918 TO: Hydro Construction, Inc. 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 14 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 15 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 Hydro Construction, Inc. (Address) (an Individual), (a Partnership), (a Corporation), hereinafter referred to as the "Principal" and (Firm) (Address) 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 Day day of Month, Year, a copy of which is hereto attached and made a part hereof, for the performance of The City of Fort Collins Work Order, titled Work Order Project Title, Work Order Number PM's Tracking #, dated Work Order Date, 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 16 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 17 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 Hydro Construction, Inc. (Address) (an Individual), (a Partnership), (a Corporation), hereinafter referred to as the "Principal" and (Firm) (Address) 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 Day day of Month, Year, a copy of which is hereto attached and made a part hereof, for the performance of The City of Fort Collins Work Order, titled Work Order Project Title, Work Order Number PM's Tracking #, dated Work Order Date, 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 18 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 19 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 20 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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: WTF Site Work – Paving & Grading DATE OF SUBSTANTIAL COMPLETION: LOCATION: Fort Collins, Colorado OWNER: City of Fort Collins PROJECT OR SPECIFIED PART SHALL CONTRACTOR: Hydro Construction, Inc. INCLUDE: WORK ORDER DATE: 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 21 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00640 CERTIFICATE OF FINAL ACCEPTANCE DATE: TO: 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 22 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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: Hydro Construction, Inc. (CONTRACTOR) WORK ORDER TITLE: WTF Site Work – Paving & Grading WORK ORDER NUMBER: SCP-HydroWTFSW050918 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 23 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 24 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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: Hydro Construction, Inc. (CONTRACTOR) WORK ORDER TITLE: WTF Site Work – Paving & Grading WORK ORDER NUMBER: SCP-HydroWTFSW050918 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 25 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 26 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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: Hydro Construction, Inc. TITLE: SCP-HydroWTFSW050918 WORK ORDER NUMBER: SCP-HydroWTFSW050918 WORK ORDER DATE: 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 Work Order Project Title 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 27 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 Page 28 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 Page 29 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 30 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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: NA 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. None SC-5.4.8.1. Add the following new paragraph immediately following paragraph 5.4.8 of the General Conditions: 5.4.8.1. 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 31 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 32 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 33 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 34 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 Utilities Work Order – Construction Form Official Purchasing Form Last updated 10/2017 SECTION 00950 CHANGE ORDER NO. PROJECT TITLE: CONTRACTOR: [Contractor] WORK ORDER NUMBER: 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 35 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 # SCP-HydroWTFSW050918 WORK ORDER TITLE: WTF Site Work – Paving & Grading BY: NA Sheet Title Drawing Revision Date Page 38 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 05/10/2018 Flood and Peterson PO Box 578 Greeley CO 80632 Dana Stewart, CIC, CISR (970) 266-7149 (970) 506-6845 DStewart@floodpeterson.com Hydro Construction Company Inc. 77 NW Frontage Road Fort Collins CO 80524 Phoenix Insurance Company 25623 Travelers Indemnity Company 25658 Travelers Property Casualty Company of America 25674 Pinnacol Assurance 41190 GL/AU/XS/WC x4/19 A Y DT-CO-8G990899-PHX-18 04/01/2018 04/01/2019 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 B Y DT-810-8G990899-IND-18 04/01/2018 04/01/2019 1,000,000 C 10,000 Y CUP-2J40080A-18-26 04/01/2018 04/01/2019 10,000,000 10,000,000 D Y 2091550 04/01/2018 04/01/2019 1,000,000 1,000,000 1,000,000 Project #SCP-HydroWTFSW050918 WTF Site Work – Paving & Grading City of Fort Collins is included as Additional Insured on the General, Automobile, and Umbrella Liability Policies if required by written contract or agreement and with respect to work performed by Insured subject to the policy terms and conditions. City of Fort Collins 700 Wood Street Fort Collins CO 80521 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. $ $ $ PROPERTY DAMAGE $ BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOS ONLY AUTOS NON-OWNED OWNED SCHEDULED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER (MM/DD/YYYY) LIMITS POLICY EXP (MM/DD/YYYY) POLICY EFF LTR TYPE OF INSURANCE POLICY NUMBER INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB EACH OCCURRENCE $ AGGREGATE $ $ OCCUR CLAIMS-MADE DED RETENTION $ PRODUCTS - COMP/OP AGG $ GENERAL AGGREGATE $ PERSONAL & ADV INJURY $ MED EXP (Any one person) $ EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 $ - $ - 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 37 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9 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 36 of 38 DocuSign Envelope ID: 31059826-3444-45A3-BD4B-E1B7A20AA4E9