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Home My WebLink AboutJob 1. R. Burke Corporation- Santa Rosa at Monterey Intersection Improvements Bid ResultsAll bid forms must be forms and required bid forms together. BID FORMS completed and submitted with your bid. Failure to submit these bond is cause to reject the bid as nonresponsive. Staple all bid THE UNDERSIGNED, agrees that they have carefully examined: 1. the location of the proposed work 2. the plans and specifications 3. read the accompanying instructions to bidders and propose to furnish all: 4. materials 5. labor to complete all the required work satisfactorily in compliance with 6. plans 7. specifications 8. special provisions for the prices set forth in the bid item list: BID ITEM LIST FOR SANTA ROSA AT MONTEREY INTERSECTION IMPROVEMENTS, SPECIFICATION NO. 1000559 Item Item Unit of Estimated Item Price Total No. j SS(1) Description _ Measure Quantity in figures) in figures) I TRAFFIC CONTROL PLAN AND $200,000.00 1 7,12 LS 1 --------- IMPLEMENTATION $9,000.00 COMPLY WITH NIGHT WORK Z LS 1 ------------- PERMIT NW CURB RAMP: SANTA ROSA $76,000.00 3 73 LS 1 AND MONTEREY _ 4 73 NE CURB RAMP: SANTA ROSA LS 1 ---- $89,000.00 AND MONTEREY SW CURB RAMP: SANTA ROSA $76,000.00 5 73 1 LS 1 ---------- AND MONTEREY COMPLY WITH MITIGATION $5,000.00 MEASURES AND 6 14 LS 1 ----- -- ARCHAEOLOGICAL MONITORING PLAN REMOVAL OF EXISTING $17,000.00 7 15 STRIPING AND PAVEMENT LS 1 ------------ MARKINGS _ TEMPORARY STRIPING AND $10,000.00 1 LS 1 PAVEMENT MARKINGS PAVEMENT $8.00 $840.00 9 84 MARKINGS/LEGENDS (ARROWS, SQFT 105 WORDS, SYMBOLS, ETC.) 10 84 GREEN BIKE LANE COATING SQFT 630 $15.00 P—,4 5-9.�� BID FORMS A BID FORMS Item Item Unit of Estimated Item Price Total No. SS , Description Measure Quantity in figures) in figures) 11 84 GREENBACK SHARROW EA 2 $1,200.00 $2,400.00 12 84 GREEN BIKE LANE (CASE 2) LF 200 $21.00 $4,200.00 13 84 GREEN BIKE LANE (CASE 3) LF 89 $39.00 $3,471.00 14 84 RED CURB PAINT LF 82 $6.00 $492.00 15 84 12' WHITE LF 4S2 $7.00 $3,164.00 16 84 24" WHITE LF 463 $15.00 $6,945.00 17 84 DETAIL 22 DETAIL 38 LF 160 $10.00 $1,600.00 18 84 LF 57 12.00 $684.00 19 84 DETAIL 39 LF 148 $7,00 $1,036.00 20 5 RESET EXISTING BENCHMARK EA 1 $4,000.00 $4,000.00 REMOVE (E) PARKING METER $400.00 $400.00 21 15 EA 1 POST 22* 73 SIDEWALK ALLOWANCE SQFT 50 $63.00 $3,150.00 23* 73 CURB AND GUTTER ALLOWANCE LF 10 $200.00 $2,000.00 ADJUST WATER VALVE PER ENG. $3,000.00 $12,000.00 24 15 EA 4 STD.6040 ADJUST GAS VALVE TO FINSHED $3,000.00 $3,000.00 2S 15 EA 1 GRADE 26 39,73 8" PCC REPLACEMENT SQFT 5,400 $37.00 $199,800.00 HMA SURFACE COURSE & $425.00 $66,725.00 27 39 TON 157 LEVELING COURSE PAVING GRID NW CORNER SIGNAL 28 39,96 SQFT 7,630 $3.00 $22,890.00 $146,000.00 29 (S) 86 IMPROVEMENTS: SANTA ROSA LS 1 ------ AND MONTEREY NE CORNER SIGNAL $101,000.00 30 (S) 86 IMPROVEMENTS: SANTA ROSA LS 1 ---------- AND MONTEREY SW CORNER SIGNAL $161,000.00 31 (S) 86 IMPROVEMENTS: SANTA ROSA LS 1 -- AND MONTEREY SE CORNER SIGNAL $123,000.00 32 (S) 86 IMPROVEMENTS: SANTA ROSA LS 1 --- - AND MONTEREY CHANGEABLE MESSSAGE SIGN - $7,000.00 $14,000.00 33 12 EA 2 PHASE 1 CHANGEABLE MESSSAGE SIGN - $9,000.00 $36,000.00 34 12 EA 4 PHASE 2 REMOVE EXISTING AND INSTALL $15,000.00 $15,000.00 35 77 EA 1 (N) 3'X2' CATCH BASIN BID FORMS BID FORMS Item Item Unit of Estimated Item Price Total No. SS(„ Description Measure Quantity (in figures) in figures) REMOVE EXISTING AND INSTALL $550.00 $17,050.00 36 77 (N)12" DIP STORMDRAIN LF 31 $4,500.00 CONNECT TO (E) �RMDRAIN $13,500.00 37 77 STRUCTURE PER ENG. STD. 3540 EA 3 COORDINATION WITH UTILITY $9,000.00 9,000.00 38 77 COMPANIES TO ADJUST LS 1 trY(ISTING INFRASTRUCTURES Bid Total $1,465,797.00 Company Name: R. Burke Corporation (1) refers to section in the Standard Specifications, with modifications in the Special Provisions, that describe required work. ,r OId item exempt from Section q-1.06 of the Standard Specifications. The unit price will not be adjusted regardless of the final bid Item quantity, (S) Indicates Speclalty Items of work per section 6-1.13A of the Standard Speciflcatlons. BID FORMS RI[] FORMS LIST OF SUBCONTRACTORS Pursuant to Section 4100 of the Public Contracts Code and section 2-1.33C of the standard specifications, the Bidder is required to furnish the following information for each Subcontractor performing more than 1/2 percent (0.5%) of the total base bid. Do not list alternative subcontractors for the same work. Subcontracting must not total more than fifty percent (50%) of the submitted bid except as allowed in section 5-1,13 of the standard specifications. For Streets & Highways projects, subcontractors performing less than ten thousand dollars ($10,000) worth of work need not be mentioned. Subcontractors required to pay prevailing wage, must be registered with the Department of Industrial Relations pursuant to Labor Code section 1725.5 to be listed. NOTE: If there are no subcontractors, write "NONE" and submit with bid. DIR Public % of Works Address and Phone Specific Total Name Under Which Registration Number of Office, Mill or Description of Base Subcontractor is Licensed License Number Number Shop Subcontract Bid Chrisp Company CA Lic#374600 1000000306 D 2280 Lilac Ave Traffic Control 1 L.� D Bloomington, CA 92316 Striping 909-746-0356 Pavement Markings U Lee Wilson Electric CA Lic#851738 1000007719 P.O. Box 250 Signal Improvements z a Company, Inc. Arroyo Grande, CA 93421 805-489-0248 Attach additional sheets as needed. BID FORMS D BID FORMS PUBLIC CONTRACT CODE SECTION 10285.1 STATEMENT In compliance with Public Contract Code Section 10285.1 (Chapter 376, Stats. 1985), the bidder hereby declares under penalty of perjury under the laws of the State of California that the bidder, or any subcontractor to be engaged by the bidder, has , has not V been convicted within the preceding three years of any offenses referred to in that section, including any charge of fraud, bribery, collusion, conspiracy, or any other act in violation of any state or federal antitrust law in connection with the bidding upon, award of, or performance of, any public works contract, as defined in Public Contract Code Section 1101, with any public entity, as defined in Public Contract Code Section 1100, including the Regents of the University of California or the Trustees of the California State University. The term "bidder" is understood to include any partner, member, officer, director, responsible managing officer, or responsible managing employee thereof, as referred to in Section 10285.1. NOTE: The bidder must place a check mark after "has" or "has not' in one of the blank spaces provided, The above Statement is part of the Bid. Signing this Bid on the signature portion constitute signature of this Statement. Bidders are cautioned that making a false certification may subject the certifier to criminal prosecution. PUBLIC CONTRACT CODE SECTION 10162 QUESTIONNAIRE In compliance with Public Contract Code Section 10162, the Bidder must complete, under penalty of perjury, the following questionnaire: Has the bidder, any officer of the bidder, or any employee of the bidder who has a proprietary interest in the bidder, ever been disqualified, removed, or otherwise prevented from bidding on, or completing a federal, state, or local government project because of a violation of law or a safety regulation? Yes V No If the answer is yes, attach a letter explaining the circumstances PUBLIC CONTRACT CODE SECTION 10232 STATEMENT In compliance with Public Contract Code Section 10232, you hereby state under penalty of perjury, that no more than one final unappealable finding of contempt of court by a federal court has been issued against you within the immediately preceding two-year period because of your failure to comply with an order of a federal court which orders you to comply with an order of the National Labor Relations Board. LABOR CODE SECTION 1725.5 STATEMENTS The bidder has delinquent liability to an employee or the state for any assessment of back wages or related damages, interest, fines, or penalties pursuant to any final judgment, order, or determination by a court or any federal, state, or local administrative agency, including a confirmed arbitration award. Any judgment, order, or determination that is BID FORMS E BID FORMS under appeal is excluded, provided that the contractor has secured the payment of any amount eventually found due through a bond or other appropriate means. Yes V No The bidder is currently debarred under Section 1777.1 or under any other federal or state law providing for the debarment of contractors from public works. Yes V No NOTE: The above Statements and Questionnaire are part of the Bid. Signing this Bid on the signature portion constitute signature of this Statement and Questionnaire. Bidders are cautioned that making a false certification may subject the certifier to criminal prosecution. BID FORMS F BID FORMS NON -COLLUSION DECLARATION Robert E. Burke declare that I am President of R. Burke Corporation the party making the foregoing bid that the bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the bid is genuine and not collusive or sham; that the bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or that anyone refrained from bidding; that the bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the bidder or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other bidder, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true; and, further, that the bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid. Executed on , 20 L Z- , in `5 AN $14, Pa (- A- I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. (SEAL) �- Robert E. Burke, President (Signatu and Title of Declarant) Subscribed and sworn to before me this day of 20 See Attached Form for Notary Certificate Notary Public Company Name: R. Burke Corporation BID FORMS G CALIFORNIA JURAT WITH AFFIANT STATEMENT See Attached Document (Notary to cross out lines 1-6 below) 0 See Statement Below (Lines 1-6 to be completed only by document signer(s), not Notary) 6 A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California Subscribed and sworn to (or affirmed) before me on County of SQy` W" �iSed this 30 day of 376\& , 20 ZZ-, by Name of Signer proved to me on the basis of satisfactory evidence be the person who appeared before me .�? •" GOLE REIGHEK Commission • 2265028 (an` N k •rr Notary Public - California (2) £ San Luis Obispo County 3 Name of Signer My Comm. Expires APR. 12, 2023 f proved to me on the basis of satisfactory evidence be the person who appeared before me.) Place Notary Seal Above Signature L Signature of Notary Public OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Further Description of Any Attached Document Title or Type of Document: Q I Document Date: Signer(s) Other Than Named Above: F'0Yv'3 Number of Pages: BID FORMS BIDDER ACKNOWLEDGEMENTS By signing below, the bidder acknowledges and confirms that this bid is based on the information contained in all contract documents, including the notice to bidders, plans, specifications, special provisions, and addendum number(s) --4� . (Note: You are responsible to verify the number of addenda prior to the bid opening.) The undersigned further agrees that in case of default in executing the required contract, with necessary bonds, within eight days, (not including Saturdays, Sundays, and legal holidays), after having received a mailed notice that the contract is ready for signature, the proceeds of the check or bond accompanying his bid will become the property of the City of San Luis Obispo. Licensed in accordance with an act providing for the registration of contractors, License No. 264193 Expiration Date o1/31l2m . The above statement is made under penalty of perjury, and any bid not containing this information "will be considered non -responsive and will be rejected" by the City. Signature of Bidder fb -et4 Robert E. Burke President (Print Name and Title of Bidder) DIR— Public Works Registration No: 1000007955 Business Name (DBA): R. Burke Corporation Owner/Legal Name; Robert E. Burke Indicate One: ❑Sole -proprietor ❑ Partnership 4/Corporation List Partners/Corporate Officers: Robert E. Burke, President Name Title Joann_ a Burke, Vice_ President/Secretary Name Title Kathy Burke, Treasurer Name Title Business Address P.O. Box 957, San Luis Obispo. CA 93406 Street Address 865 Capitolio Way, San Luis Obispo, CA 93401 Mailing Address _P.O. Box 957 _ City, State, Zip Code San Luis Obispo, CA 93406 Phone Number 805-543-8568 Fax Number 805-543-2521 Email Address Rbcna rburkecorporation.com Date 06/30/2022 Ulu rumlvlO H BID FORMS QUALIFICATIONS Failure to furnish complete reference information ON THIS FORM, as specified in this project's Notice to Bidders and indicated below, is cause to reject the bid. Additional information may be attached but is not a substitute for this form. Reference Number 1 Customer Name & Contact Individual City of Guadalupe, Andrew Carter Telephone & Email acarter@ci.guadalupe.ca.us Pro1ect Name Site Address): 2020-001 2020 ATP Cycle 3 Pedestrian Improvements Did this project include roadway Describe the services provided and how this project is similar to paving and curb ramp construction that which is being bid: within t e public right of way? ADA Curb Ramps Yes _ No_ o- __ --. Curb, Gutter, Sidewalk, Driveway Apron Was th' contract for a public agency? Rec Rapid Flashing Beacon - Solar Yes 17 No Date project completed: 07/2020 Reference Number 2 Customer Name & Contact Individual City of Grover Beach, Erin Wiggin Telephone & Email 805-473-4550 , ewiggin@groverbeach. Project Name (Site Address): Did this project include roadway paving and curb ramp construction within Oie public right of way? Yes V No ❑ Was th}'a contract for a public agency? Yes %! No ❑ Describe the services provided and how this project is similar to that which is being bid: Curb Ramp Crosswalk Curb & Gutter Date Reference Number 3 Customer Name & Contact Individual City of San Luis Obispo, Brian Rodriguez 01 /2021 Telephone & Email 805-781-7226, brodrigu@slocity.org Project Name (Site Address): 2021 Downtown Pavement Improvements Did this project include traffic signal Describe the services provided and how this project is similar to improvements within the public right that which is being bid: of way? Remove & Replace Curbs, Gutters, Sidewalks & Driveways Yes V No ❑ --- Traffic Control Plan & Implementation Was ttys contract for a public agency? HMA Surface and Leveling Course Yes V No ❑ Date oroiect completed: 03/2022 BID FORMS I BID FORMS ATTACH BIDDER'S BOND TO ACCOMPANY BID Know all men by these presents: That we R. Burke Corporation . AS PRINCIPAL, and The Ohio Casualty Insurance Company AS SURETY, are held and firmly bound unto the City of San Luis Obispo in the sum of. - Ten Percent of Bid Amount Dollars ( 10% of Bid J to be pald to said City or its certain attorney, Its successors and assigns; for which payment, well and truly to be made, we bind ourselves, our heirs, executors and administrators, successors or assigns, jointly and severally, firmly by these presents: THE CONDITION OF THIS OBLIGATION IS SUCH, that if the certain bid of the above bounden R. Burke Corporation toeonstruct Specification No. 1000559 Santa Rosa at Monterey Intersection Improvements (insert name of street and limits to be improved or project) dated June 30, 2022 Is accepted by the City of San Luis Obispo, and If the above bounden R. Burke Corporation , his heirs, executors, administrators, successors, and assigns shall duly enter Into and execute a contract for such construction and shall execute and deliver ft two bonds described within ten (10) days (not Including Saturdays, Sundays, or legal holidays) after the above bounden, R. Burke Coporation , has received notice by and from the said City of San Luis Obispo that said contract Is ready for execution, then this obligation shall become null and void; otherwise, it shall be and remain In full force and virtue. IN WITNESS WHEREOF, we hereunto set our hands and seals thls28th day of June , 2022 Bidder Principal: R. Burke Corporation (�tl Signature Date Title: Robert E. Burke, President Surety: The Ohio Casualty Insurance Company Myrna Smith, Attorney -in -Fact Bidder's signature Is not required to be notarized. Surety's signature must be notarized. Equivalent form may be substituted (aw. $470-14) BID FORMS J ;W i� i> i ca This Power of Attorney limits the acts of those named herein, and they have no authority to bind the Company except in the manner and to the extent herein stated. Liberty Liberty Mutual Insurance Company Mutual, The Ohio Casualty Insurance Company Certificate No:8201903-969577 SURETY West American Insurance Company POWER OF ATTORNEY KNOWN ALL PERSONS BY THESE PRESENTS: That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire, that Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts, and West American Insurance Company is a corporation duly organized under the laws of the State of Indiana (herein collectively called the "Companies"), pursuant to and by authority herein set forth, does hereby name, constitute and appoint, Britton Christiansen; Myrna Smith: Philip E. Vega: Kevin E. Vega all of the city of Covina state of California each individually if there be more than one named, its true and lawful attorney -in -fact to make, execute, seal, acknowledge and deliver, for and on its behalf as surety and as its act and deed, any and all undertakings, bonds, recognizances and other surety obligations, in pursuance of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons. IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed thereto this 15th day of August , 2019 Liberty Mutual Insurance Company P` 1NSU Pam, V INSV 1NSU,p4 The Ohio Casualty Insurance Company �J ooN°O°�T r'n yJ G %P0 1 ;1 `4P-oaPO'- jn West American Insurance Company °o to ue 3 °o m w 3 Fo m 1912 1991 0 C 1919 „ ce1ls�dL y ;A 410 MAUPB`�� db3 �s 'houen dL ' '��• ��> *� �'yl . ►� �M r *� By: David M. Carey, Assistant Secretary State of PENNSYt VANIA County of MONTGOMERY ss On this 15th day of August , 2019 before me personally appeared David M. Carey, who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance O Company, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do, execute the foregoing instrument for the purposes = therein contained by signing on behalf of the corporations by himself as a duly authorized officer. c� LIJ IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my notarial seal at King of Prussia, Pennsylvania, on the day and year first above written. r rr 5� OrtryAq(%r COMMONWEALTH OF PENNSYLVANIA �Q = y Notarial Seal OF Teresa Pastella, Notary Public Upper Merion Twp., Montgomery County By: IS P My Commission Expires March 28, 2021 My Member, Pennsylvania Association of Notaries Notary This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows: ARTICLE IV — OFFICERS: Section 12 Power of Attorney. Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject to such limitation as the Chairman or the President may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, acknowledge and deliver as surely any and all undertakings, bonds, recognizances and other surety obligations. Such attorneys -in -fact, subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation When so executed, such instruments shall be as binding as if signed by the President and attested to by the Secretary Any power or authority granted to any representative or attorney -in -fact under the provisions of this article may be revoked at any time by the Board, the Chairman, the President or by the officer or officers granting such power or authority. ARTICLE XIII — Execution of Contracts: Section 5. Surety Bonds and Undertakings. Any officer of the Company authorized for that purpose in writing by the chairman or the president, and subject to such limitations as the chairman or the president may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Such attorneys -in -fact subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so executed such instruments shall be as binding as if signed by the president and attested by the secretary. Certificate of Designation — The President of the Company, acting pursuant to the Bylaws of the Company, authorizes David M. Carey, Assistant Secretary to appoint such attorneys -in - fact as may be necessary to act on behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Authorization — By unanimous consent of the Company's Board of Directors, the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the Company, wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds, shall be valid and binding upon the Company with the same force and effect as though manually affixed. I, Renee C. Llewellyn, the undersigned, Assistant Secretary, The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company do hereby certify that the original power of attorney of which the foregoing is a full, true and correct copy of the Power of Attorney executed by said Companies, is in full force and effect and has not been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this 28th day of June , 2022 . P� INSU� P�,SY INSv a 1kSU�p9 1912 0 0 1919 2�1991�n d o a o ~d��'s+cNue`ada ° N�MPe `��a� ro 'NOIA 1, a0� By Renee C. Llewellyn, Assistant Secretary y . * �S1 + ► M : IN 00 Q� O� N � 1 Cal o 0 v_ a> co � >o Iv — a✓ M 8o oCD LMS-12873 LMIC OCIC WAIC Multi Co 062018 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 •.rcc,c:oc�csca..cc.�:ccrcrc:-c,�.-c�ccccrcrcocccccr,�,c:c.�:c�-rcccr.�rss:cry.r...rccx�cxxc,�c.�c.�c�xsxc�•c�.,cc:u A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of San Luis Obispo On J 2416' before me, Date Christina Doherty, Notary Public Here Insert Name and Title of the Officer personally appeared Myrna Smith Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(es), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. !� CHRISTINA DOHERTY f� \ Notary Public - California ;r•- ;- San Luis Obispo County I ?' •'y Commission � 2327820 My Ceram Expires Jun 1, 2024 I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature t Signature of Not ry Public Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Document Date: Signer(s) Other Than Named Above; Capacity(ies) Claimed by Signer(s) Signer's Name: O Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual 0 Attorney in Fact ❑ T rustee ❑ Guardian or Conservator ❑ Other: _ Signer Is Representina: Number of Pages: Signer's Name: _ ❑ Corporate Officer — Title(s): - 0 Partner — C1 Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: 02015 National Notary Association • www.NationalNotary.org - 1-800-US NOTARY (1-800-876-6827) Item Ii5907