Hardy & HarperCITY OF ROSEMEAD
ANNUAL RESIDENTIAL RESURFACING PROJECT
MUSCATEL AVENUE
FROM GRAND AVENUE TO MARSHALL AVENUE
PROJECT No. 21846
CONTRACT BID FORMS
SECTION 1 - BID SCHEDULE
CBF -0
BIDDER: Maj: a 9. "qrTr"Toc
CONTRACT BID FORMS
TABLE OF CONTENTS
SECTION BID SCHEDULE_ ...................................................................... ..............................1
SECTION 2 BID DATA FORMS ................................................................... ............................... 5
2.A BID BOND ................................................................................. ............................... 6
2.13 LIST OF PROPOSED SUBCONTRACTORS .......................... ............................... 7
SECTION 3 NON - COLLUSION AFFIDAVIT .............................................. ............................... 10
BID SCHEDULE
SCHEDULE OF PRICES FOR
ANNUAL RESIDENTIAL RESURFACING PROJECT
MUSCATEL AVENUE
FROM GRAND AVENUE TO MARSHALL AVENUE
PROJECT No. 21846
BASE BID SCHEDULE
7
6
CBF -1
UNIT OF
EST.
UNIT
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
1
Clearing & Grubbing per plans
LS
1
and specifications. See technical
provisions TP- 2,TP- 3 &TP-4.
3ri�00p.00
3G� o00•aa
2
Disposal of Waste Materials.
LS
1
3 as f 92
3 a y 92
3
Cold mill 2.0- inches thick existing
SF
208,172
pavement.
Q l If
oZq `ry 4 ,f>
4
Construct 1.5 inches thick
TONS
1,950
pavement overlay ARHM -GG-C
(PG 64 -16) as indicated on the
plans.
b'a ., o
/ G0� �7S• 0
5
Construct 0.5 inches thick
TONS
655
Asphaltic Leveling course D1
(PG 64 -10) as indicated on the
ga S�
sy 1) 37 sd
plans.
6
Remove, Dispose and Construct
SF
6,755
4- inches thick PCC Sidewalk per
SPPWC Std. Plan 113 -1.
5 J
.,r0
7
Remove, Dispose and Construct
SF
2,350
PCC Driveway Approaches per
SPPWC Std. Plan 110 -2.
GP
f8 y p0
8
Remove, Dispose and Construct
LF
1,214
8- inches Curb and 24- inches
2 0 22 r per SPPWC Std. Plan
y'?&' O
Yq O D
/
9
Remove, Dispose and Construct
LF
200
8- inches PCC Curb Only per
SPPWC Std. Plan 120 -2.
36- 00
7 0?LV •
10
Remove, Dispose and Construct
SF
416
PCC Cross Gutter per SPPWC
Std. Plan 123 -2.
/� : Q U
ro
7
6
CBF -1
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ Y 5 6 - 'f U O C) - U d
F V e- ha - 4 i v t �h a/Jl�4.eS
Dollar amount in written farm C. n al .v d C eur fir.
Note: The City of Rosemead reserves the right to reduce or increase the quantities of any items in
the schedule of bid items above, within the limits define in Section 3 -2.2.1 of the Standard
Specifications, to stay within the budgeted amount of this project.
If the Bid Documents specify alternate bid items, the following Alternate Bid amounts shall
be added to or deducted from the Total Bid Price entered above. The owner can choose to
include one or more of the alternates in the Total Bid Price of the Project. If any of the
Alternate Bids are utilized by the Owner, the resulting amountshall be considered the Total
Bid Price for the Project.
9
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and
after the bid opening date, or until a Contract for the Work is fully executed by the Owner and a third
party, whichever is earlier. The undersigned also agrees that if there is a discrepancy between the
written amount of the Bid Price and the numerical amount of the Bid Price, the written amount shall
govern.
Attached hereto is a certified check, a cashier's check or a id bon in the amount of
fT /. Dollars ($ said amount being not less than ten percent (10 %) of the Total
CBF -2
UNIT OF
EST.
UNIT
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
11
Remove, Dispose and Construct
EA
20
PCC Curb Ramps per SPPWC
Std. Plan 111 -4.
^
o�y 3%6:
y � g
12
Double Adjust Sewer Manhole to
Fro
30
Grade per APWA Std. Plan 205-
1 and 205
S'�p7 DO
/ 7 j Q /0. 0
-1.
13
Adjust Water Valve /Gas Valve to
EA
29
Grade.
5d. 00
/� ySO, 0
14
Install Survey Well Monument
EA
16
per City of Rosemead Std. Plan
SOB -001. See Section 2 -9
Surveying of the General
Provision -7 per details (Cover,
Sleeve & Dome will be provided
S99
9 oZ 3a o
by the City at no cost).
15
Install Traffic Striping, Traffic
LS
1
Signal Loops and Pavement
Markers per the Striping Plans
000. Od
(� 9 000. 0
and Specifications Complete.
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ Y 5 6 - 'f U O C) - U d
F V e- ha - 4 i v t �h a/Jl�4.eS
Dollar amount in written farm C. n al .v d C eur fir.
Note: The City of Rosemead reserves the right to reduce or increase the quantities of any items in
the schedule of bid items above, within the limits define in Section 3 -2.2.1 of the Standard
Specifications, to stay within the budgeted amount of this project.
If the Bid Documents specify alternate bid items, the following Alternate Bid amounts shall
be added to or deducted from the Total Bid Price entered above. The owner can choose to
include one or more of the alternates in the Total Bid Price of the Project. If any of the
Alternate Bids are utilized by the Owner, the resulting amountshall be considered the Total
Bid Price for the Project.
9
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and
after the bid opening date, or until a Contract for the Work is fully executed by the Owner and a third
party, whichever is earlier. The undersigned also agrees that if there is a discrepancy between the
written amount of the Bid Price and the numerical amount of the Bid Price, the written amount shall
govern.
Attached hereto is a certified check, a cashier's check or a id bon in the amount of
fT /. Dollars ($ said amount being not less than ten percent (10 %) of the Total
CBF -2
Bid Price. The undersigned agrees that said amount shall be retained by the Owner if, upon award,
we fail or refuse to execute the Contract and furnish the required bonds, certificates and
endorsements of insurance and other certifications within the time provided.
If awarded a Contract, the undersigned agrees to execute the formal Contract, which will be
prepared by the Owner for execution, within five (5) Calendar Days following the Letter of Award for
the Contract, and will deliver to the Owner within that same period the necessary original Certificates
of Insurance, Endorsements of Insurance, Performance Bond, Payment Bond and all other
documentation and certification required by the Contract.
The undersigned offers and agrees that if this bid is accepted, it will assign to the purchasing body
all rights, title, and interest in and to all causes of action it may have under Section 4 of the Clayton
Act (15 U.S.C. Section 15) or under the Cartwright Act (Chapter 2 of Part 2 of Division 7 of the
Business and Professional Code), arising from purchases of goods, materials or services by the
Bidder for sale to the purchasing body pursuant to the bid. Such assignment shall be made and
become effective at the time the purchasing body tenders final payment to he Contractor.
Bidder understands and agrees that, when requested by Owner, he shall provide: (1) evidence
satisfactory to the Owner of Bidder's California contractor's license(s) in good standing; (2) evidence
that the person signing this Bid is authorized to bind Bidder to this Bid and to a contract resulting
therefrom; and (3) any other information and documentation, financial or otherwise, needed by
Owner to award a Contract to the lowest responsible and responsive bidder.
The undersigned acknowledges receipt, understanding and full consideration of the following
addenda to the Contract Documents.
Addenda Nos. N0q-
The Bidder understands and agrees that the Total Bid Price is inclusive of all labor, materials, and
equipment or supplies necessary to complete the Work as described in the Bid Documents. If this
bid is accepted, the undersigned Bidder agrees to enter into and execute the Contract with the
necessary bonds and accept the Total Bid Price as compensation in full for all Work under the
contract.
CBF -3
Bidder acknowledges that data submitted with its Contract Bid Forms which it requires to be
incorporated into a Contract arising out of this Submittal has been so identified by Bidder. Bidder
further acknowledges that the Owner may, at its discretion, incorporate any of the remaining data
submitted herewith into a contract arising out of this Bid.
By:
Signature
&C Me K(V56nrl
Type or Print Name
Vine Q r tn± 0 fee j ai-'v)rts
Title
131a C-a6i 1NQrwey.Ay". p
Business Street Address
% AM, C.A CIA
City, State and Zip Code
71N -444 -1195(
Telephone Number
Bidder's/Contractor's State of Incorporation: C41 i -Forr) j a
Partners or Joint Venturers:
Bidder's License Number(s): a 15g5A
NOTES:
1) By its signature on this Bid, the Bidder certifies under penalty of perjury the accuracy of the
representations made on the Contract Bid Forms.
2) If Bidder is a corporation, enter State of Incorporation in addition to Business Address
3) If Bidder is a partnership or joint venture, give full names of all partners or joint
venturers.
As further discussed in the Instructions to Bidders, Bidder will be required
to provide evidence that the person signing on behalf of the corporation,
nartnershin or joint venture has the anthnrity to do so.
CBF -4
MINUTES OF SPECIAL MEETING OF
BOARD OF DIRECTORS OF
HARDY & HARPER, INC.
The Special Meeting of the directors of HARDY & HARPER, INC., California
Corporation, was held on December 1, 2009 at the principal office of the corporation.
The following directors were present at the meeting:
FRED T. MAAS, JR.
STEVEN M. KIRSCHNER
KRISTEN S. PAULINO
The following persons also were present:
None
The chair called meeting to order and notice of the meeting is hereby waived.
The chair called the meeting to order and announced that the meeting was held
pursuant to the waiver of notice and consent to the holding of the meeting.
It was then resolved to dispense with the reading of the minutes of the last
meeting.
The purpose of this special meeting is the discussion of authorizing Corey
Kirschner as vice - president of the company to sign contracts of behalf of the company.
After some discussion it is now hereby resolved:
THEREFORE, UPON MOTION MADE AND CARRIED, the corporation authorizes
Corey Kirschner as vice - president of the company to sign contracts on behalf on the
company and has authority to bind the company by his signature as vice- president.
There being no further business to come before the meeting, the meeting was duly
adjourned.
�"W�L '. w
RISTEN S. PAULINO, SECRETARY
SECTION 2
BID DATA FORMS
CBF -5
2.B LIST OF PROPOSED SUBCONTRACTORS
In compliance with the "Subletting and Subcontracting Fair Practices Act," Sections 4100
through 4114 of the California Public Contract Code, and any amendments thereto, each
Bidder shall provide the information requested below for each subcontractor who will
perform work, labor or render service to Bidder in or about the construction of the Work in an
amount in excess of one -half of one percent (greater than 0.5 %) of the Bidders Total Bid
Price, or, in the case of bids or offers for the construction of streets or highways, including
bridges, in excess of one -half of 1 percent of the Contractor's total bid or ten thousand
dollars ($10,000), whichever is greater, and shall further set forth the portion of the Work
which will be done by each subcontractor. Bidder shall list only one subcontractor for any
one portion of the Work.
Pursuant to Public Contract Code Section 4104, the Owner has determined that it will allow
Bidders twenty -four (24) additional hours after the deadline forsubmission of bids to submit
the information requested by the Owner about each subcontractor, otherthan the name and
location of each subcontractor.
If the Bidder fails to specify a subcontractor for any portion of the Work to be performed
under the Contract, it shall be deemed to have agreed to perform such portion itself, and
shall not be permitted to subcontract that portion of the Work except under the conditions
Subletting or subcontracting of any portion of the Work in excess of one half of one percent
(greater than 0.5 %) of the Total Bid Price or, in the case of bids or offers for the construction
of streets or highways, including bridges, in excess of one -half of 1 percent of the
Contractor's total bid or ten thousand dollars ($10,000), whichever is greater, for which no
subcontractor was designated in the original bid shall only be permitted in cases of public
emergency or necessity, and then only after Owner approval.
CBF -7
Name and Location
of Subcontractor
Name:
Address:
Description of Work
to be Subcontracted
Name and Location
of Subcontractor
Name:
Address:
Description of Work
to be Subcontracted
CBF -8
f
BIDDER: HOYdu q. �{�r pfr
— rr
2.13 LIST OF PROPOSED SUBCONTRACTORS (continued)
[ Duplicate Next 2 Pages If needed far listing additional subwntractors." J
Name and Location
Description of Work
of Subcontractor
to be Subcontracted
Name: FQ
Address: / 3.2A
CO ron , % t
Name and Location
Description of Work
of Subcontractor
to be Subcontracted
Name:
Address: O r n k✓ t
9 a 9 �t2 Grp
L,a Au ceaQ
Name and Location
Description of Work
of Subcontractor
to be Subcontracted
6.0-
Name: C-
Address : So ++ti4e-r goc
C> roe n c� 4 1 C j+ q j 6 Y
Name and Location
of Subcontractor
Name:
Address:
Description of Work
to be Subcontracted
Name and Location
of Subcontractor
Name:
Address:
Description of Work
to be Subcontracted
CBF -8
IC ■■ Hard ■ /
2.0 REFERENCES
The following are the names, addresses and telephone numbers for three public agencies for which BIDDER
has performed similar work within the past two (2) years:
1.
Name and
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
2.
Name and Address of Owner
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
3.
Name and Address of Owner
Name and telephone number of person familiar with project
Contract amount Type of Work, Date Completed
17
and Address of Owner
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
CBF -9
Attachment A
Marry e0farper, Inc.
Owner /Agency Contact Project (Amount & End Date)
City of Paramount
Juan de Castro, PE
FY 2012 Arterial Street
16400 Colorado Ave.
(562)220 -2020
Resurfacing
Paramount, CA 90723
f.(562)220 -2105
$ 747,000.00 10/12
City of Palos Verdes Estates
Floriza Rivera, PE
2012/13 Overlay Project
340 W. Palos Verdes Drive
(310)378 -0383 x 2221
Palos Verdes Estates, CA
frivera @pvestates.org
90723
$ 747,000.00 10/12
City of Desert Hot Springs
Hal Goldenberg, PE
2012 Street Rehabilitation
65 -950 Pierson Blvd.
(760)329 -6411
Program, Phase 2
Desert Hot Springs, CA
hgoldenberg @cityofdhs.org
92240
$ 1,212,000.00 11/12
2012 Grind & Overlay
City of Perris
Chris Sunde, PE
Rehabilitation /
101 N. "D" St.
Tri Lakes Consultants
Metz Rd. & Goetz Rd.
Perris, CA 92572
(951)943 -6504
Paving Project
chris @trilakeconsultants.com
$ 789,000.00 11/12
City of Orange
Alan Truong, PE
FY 11/12 CDBG Alley &
300 E. Chapman Ave.
(714)744 -5568
Street Improvements
Orange, CA 92866 -1508
atruong @cityoforange.org
$ 755,000.00 12/12
Attachment A
9fardy e0farrer, Inc.
Owner /Agency Contact Project (Amount & End Date)
City of Glendale
Sarkis Oyanesyan, PE
East Glenoaks Boulevard
633 E. Broadway
(818)937 -8246
Rehabilitation Project
Glendale, CA 91206
aaivazyan @ci.glendale.ca.us
$ 1.545.000 00 2/13
FY 11/12 Street Rehabilitation
Project
$1,441,000.00 3/13
City of Glendora
Jason Roehrborn, PE
FY 2012 -13 Citywide
116 E. Foothill Blvd.
(626)914 -8253
Street Rehab Phase 1
Glendora, CA 91741 -0338
jroehrborn @ci.glendora.ca.us
$ 456,000.00 3/13
City of Laguna Niguel
Frank Borges, PE
FY 12/13 Paving Rehab &
30111 Crown Valley Pkwy
(949)362 -4325
Sub Drain Improvements
Laguna Niguel, CA 92677
fborges @ci.laguna- niguel.ca.us
$ 777,000.00 4/13
City of Montebello
Joe Boada, PE
Union Street & Slauson
1600 W. Beverly Blvd.
(323)887 -1460
Avenue
Montebello, CA 90640
jboada @cityofmontebello.com
$ 358,000.00 4/13
City of Santa Ana
Carlos Castellanos, PE
McFadden Ave., Lyon St.
20 Civic Center Plaza M -22
(714)647 -5642
Main St./ 1st St.
Santa Ana, CA 92701
ccastellanos @santa- ana.org
Intersection
$ 1,049,000.00 4/13
��.� d - -u' I
SECTION 3
NON - COLLUSION AFFIDAVIT
CBF -10
NON - COLLUSION AFFIDAVIT
In accordance with Public Contract Code Section 7106, the undersigned, being first duly
sworn, deposes and says that he or she holds the position listed below with the bidder, 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 shall refrain 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. el
Shinature
Corey Y% rsahnar'
Typed or Printed Name
Vies 9rQ6,14A t+ 2 paa+iinvt5
Title
Bidd
T� rTOAr.�inG.
er
Subscribed and sworn before me
This _ day of 20_
(Seal)
Notary Public in and for
the State of California
My Commission Expires:
S'e-e , 4i+aalned IUO- - O✓ial S't"': 'sbo` COmecby-,
CBF - 11
CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202
Pq See Attached Document (Notary to cross out lines 1 -6 below)
❑ See Statement Below (Lines 14 to be completed only by document signerfs], not Notary)
y
n
5
Signature of Document Signer No. 2 (if any)
State of California
County of Orange
DEBBIE MATSEN
@MyComm.Expires Commission # 1950174
Notary Public - California Riverside County
Nov 22, 2015
Piece Note" Seel Above
Subscribed and sworn to (or affirmed) before me
on this 5th day of August 20 13
Date Non01 Year
by
(1) Corey Kirschner
Nome of Signer
proved to me on the basis of satisfactory evidence
to be the person who appeared before me (.) (,)
(and
Name of Signer
proved to me on the basis of satisfactory evidence
to be the person who appeared before me.)
Signature CQ,�111A, TQCX=N�
Signature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable Top of thumb here Top of thumb here
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
The or Typo of Document: Non - Collusion Affidavit
Document Dale: AUgUSt 5 201 Number of Pages: 1
Signer(s) Other Than Named Above: None.
0 2010 National Notary Association • NatlonalNotary.org • 1- e00 -US NOTARY (1 -600- 616-6627) Item ASD10
Signature or Document Signer No. 1
L;UL
AUG A 1 '.3 I�
BIDDER : Hardy -& Harper, Inc.
Data Forms: Bidders. shall prepare and use as many sheets as are necessary to adequately provide
the information required. Bidder shall ensure that every page of its Bid Data Forms, are properly
identified with the Bidder's name and page number.
2'.A BID BOND Bond No. RARNA -1360
KNOW ALL MEN BY THESE PRESENTS:
THAT Hardy & Harper, Inc. ,as
Principal, and International Fidelity Insurance Company
as Surety, are held firmly bound unto the
CITY OF ROSEMEAD (hereinafter called the OWNER): in the sum of
Tin Percent of Amount Aid
($ l0a * * * * * * * * * * * * ** 1 , being not less than ten percent (10 %) of the Total
Bid Price; forthe payment of which sum will and trulyto be made, webind ourselves,
our heirs, executors; administrators, successors, and assigns, jointly and severally,
firmly by these presents.
WHEREAS, said Principal has submitted a bid to the OWNER to perform all Work
required for the Annual Residential Resurfacing, Project— Muscatel Avenue
From Grand Avenue to Marshall Avenue as set forth in the Notice Inviting Bids
and accompanying Bid Documents, dated Au2ust 7. 2 013'
NOW, THEREFORE, if said Principal is awarded a Contract for the Work by the
OWNER and, within the time and in the manner required by the above- referenced
Bid Documents, enters into the written form of Contract bound with said Bid
Documents; furnishes the required bonds (one to guarantee faithful performance
and the other to guarantee payment for labor and materials) furnishes the required
insurance certificates and endorsements, and furnishes any other certifications as
may required by the Contract, then this obligation shall be null and void; otherwise
it shall remain in full force and effect. In the event suit is brought upon this bond by
the OWNER: and judgment is recovered, said Surety shall pay all costs incurred by
the OWNER in such suit, including reasonable attorneys' fees to be fixed by the
court.
SIGNED AND SEALED; this '11st day of 1111y , 20
International Fidelity
Hardy & Harper. Inc. (SEAL) Insurance Company (SEAL)'
principal Surety
By: By:
Signature Signature Dwight Reilly
Coireq �cte vieir, vi&e Pro iiiont �rul•f0at5 Attorney -in -Fact
CBF' 6
ACKNOWLEDGMENT
State of California
County of Orange )
On July 31. 2013 before me, Susan Pugh Notary n ,r,i
(insert name and title of the officer)
personally appeared Dwight Reilly
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is /am
subscribed to the within instrument and acknowledged to me that he /she(they executed the same in
his /herd authorized capacity(), and that by hislhaftaxii signature(%) on the instrument the
person(s), or the entity upon behalf of which the person(%) acted, executed the instrument.
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. susAN PUCH
�n� COMM $793 ?229 n
Notar P Blic California
C 7�
ORANGE COUNTY "
j MyComm, E piresApr29.7015
Signature \\ (Seal)
Susan Pugh
State of California
County of
Orange
On August 5, 201 3beforeme, Debbie Matsen, Notary Public
Dale Here IneeH Neme and TIGe of the Oalcet '
personally appeared
Kirschner
who proved to me on the basis of satisfactory
evidence to be the person(p) whose name(p) is /are-
subscribed to the within instrument and acknowledged
to me that he /ahefthey executed the same in
hisAael/h& authorized capacity(ies), and that by
his/hafMAW signature( on the instrument the
person( or the entity upon behalf of which the
person(j) acted, executed the instrument.
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
G DEBBIE MATSEN
° i Commission # 1958174
a . - - Notary Public - California z
z Riverside County 8
My Comm. Expires Nov 22, 2015
Place Notary Seal Above " -- Slgneture 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.
Description of Attached Document
Title or Type of Document: Bid Bond
Document Date: July 31, 2013
Signerof Other Than Named Above: Dwight
Capacity(iec) Claimed by Signer(}
Signer's Name: Corey Kirschner
14 Corporate Officer — Tilleo: VPO
❑ Individual
❑ Partner — ❑ Limited ❑ General Top ofthumIt here
• Attorney In Fact
• Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Hardy & Harper, Inc.
Signer's Name:
❑ Corporate Officer — Title(s):
❑ Individual
• Partner — ❑ Limited ❑ General Top of thumb here
• Attorney in Fact
• Trustee
• Guardian or Conservator
❑ Other:
Signer Is Representing:
-1 1
Reilly
Number of Pages: 1
On
swot
GOn
duly
Seal,
IN WITNESS WHEREOF, INTERNATIONAL FIDELITY INSURANCE COMPANY and ALLEGHENY CASUALTY COMPANY have each executed and
attested these presents on this 12th, day of March, 2012; {
_ec//al„