Electro Construction Corp.BIDDER. Electro Construction Corp.
SECTION 1- BID SCHEDULE
CBF - t
BIDDER: Electro Gonstruction Corp.
BID SCHEDULE
SCHEDULE OF PRICES FOR
ROSEMEAD PARK IMPROVEMENTS PROJECT
BASKETBALL COURTS
PROJECT No. 41020
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$
Cl /F 1I, /IllpkG/ NFNPY5,741D L/2yk E 4)
Dollar amount In written form
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 amount shall be considered the Total
Bid Price for the Project
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cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and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 cashiers check or a bid bond in the amount of
10% of Bid Dollars ($ ) said amount being not less than ten percent (10 %) of the Total
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.
CBF -2
UNIT
ITEM
NO.
ITEM DESCRIPTION
UNIT
QTY.
PRICE
COST
1
Clearing & Grubbing per plans and
LS
1
0
$1,000.0
1
$1,000.00
specifications.
2
Disposal of Waste Materials.
LS
1
$ 500.00
$ 500.00
3
Remove, Dispose Existing, Furnish
LS
1
and Install Lighting System as
//p
/ /
indicated on Plans and
Specifications Complete.
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$
Cl /F 1I, /IllpkG/ NFNPY5,741D L/2yk E 4)
Dollar amount In written form
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 amount shall be considered the Total
Bid Price for the Project
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 cashiers check or a bid bond in the amount of
10% of Bid Dollars ($ ) said amount being not less than ten percent (10 %) of the Total
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.
CBF -2
BIDDER: Electro Construction Corp.
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.
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.
The undersigned acknowledges receipt, understanding and full consideration of the following
addenda to the Contract Documents.
Addenda Nos. A14
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
By: f4
Signature
Rune A. Jensen
Type or Print Name
Chief Financial Officer
Title
Bidders /Contractor's State of Incorporation:
Partners or Joint Venturers:
BIDDER: Electro Construction Corp.
3021 Rowena Avenue
Business Street Address
Los Angeles, C4 90039
City, State and Zip Code
323 - 660 -4141
Telephone Number
California
Bidders License Number(s): 95881 C10
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)
3)
If Bidder is a corporation, enter State of Incorporation in addition to Business Address
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 corp(ration,
partnership orjoint venture has the authority to do so
CBF -4
0
I��������
ELECTRO CONSTRUCTION CORP.
EN3wEEe5 • coNTAacroas uc ssaei
UUVII IIIIIIIIIIIIIIIIII
3021ROWENAAVETUE ' LOS ANGELES, CALIFORNIA 90039 -2004 " " " "'•
VYVYV
�y
FAX: (323) 660E211
April 24, 2014
AUTHORIZED SIGNATURES OF ELECTRO CONSTRUCTION CORP.
Suzanne Jensen — President
John S. Everson — CEO
Horst G. Drexler— Vice - President
Rune A. Jensen — Chief Financial Offic
Yvonne Everson — Secretary
Jay Adams — Field Resource Manager
BIDDER. Electro Construction Corp.
SECTION 2
BID DATA FORMS
CBF -5
BIDDER: Electro Construction Corp.
Bidder shall submit its Bid data in accordance with the format shown on each of the following Bid
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
KNOW ALL MEN BY THESE PRESENTS:
THAT Electro Construction Corp.
as
Principal, and The Hanover Insurance Company
as Surety, are held firmly bound unto the
CITY OF ROSEMEAD Shereinafter called the OWNER) in the sum of
TEN PERCENT THE AMO NT BID IN---- *'• ^••••' " " ^ ^ ° ^ ^- • ^ ° ^ ^ ^ ^••• ^ ^ ^ ^ ^ ^ ^• ^•
DOLLARS
being not less than ten percent (10 %) of the Total
Bid Price; forthe payment of which sum will and truly to be made, we bind 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 ROSEMEAD PARK IMPROVEMENTS PROJECT — NORTH
PARKING LOT LIGHTING REPLACEMENT as set forth in the Notice Inviting Bids
and accompanying Bid Documents, dated April 30, 2014
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 be 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 29th day of April 2014
Electro Construction Corp (SEAL) The Hanover Insurance Company SEAL
( )
Principe Surety
By: By: ,
5i1 atur Rune, 8men Signature DONNA M. CRi
[11ieI inmi 8m en Attorney -In -Each
1491
CALIFORNIA ALL - PURPOSE ACKNOWLEDGMENT
State of California
County of Los Angeles I
On April 30,2014beforeme, M, Betty Smith, Notary Public,
bale Here Iasee Nemn ontl nnc of m¢ onlcer
personally appeared Rune A. Jensen
cml CODE g 1199
who proved to me on the basis of satisfactory
evidence to be the person(A whose name(o isaua
subscribed to the within instrument and acknowledged
to me that he /she44ay executed the same in
his/heNtheis- authorized capacity(ies), and that by
his /hw4heir signature( on the instrument the
person(yj, or the entity upon behalf of which the
person(g) acted, executed the instrument.
M. BETTY SMITH I certify under PENALTY OF PERJURY under the
Commission a` 19353fi9 laws of the State of California that the foregoing
a Notary Puelic - California i
v Los Angeles County '- paragraph is true and correct.
M Comm. Expires May 7, 2015
WITNESS my hand and official seal.
Signature: VVY.. «'4 C \Y YU, L" _.
Place Notary Seal Above Sipnalw Fflolae Nbr,
OPTIONAL
Though the informalion below is not required by law, it may prove valuable to persons relying on th acumen
and could prevent fraudulent removal and reattachmeel of this form to another docu of,
Description of Attached Document
Title or Type of Document: _
Document Date: _ Number of Pages:
Signers) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name. _ Signer's Name: _
- Corporate Officer - Tillers) _ I Corporate Officer - Title(s):
- Individual _ Individual
- Partner -1 Limped -Gene, Tpn pl 1 1, 112,9 Partner — I Gmlted — General lop onmlmu nom
Attorney in Fact Attorney in Fact
Trustee I —I Trustee
Guardian or Cc rvator I Guardian or Conservator
— Other: I Other'.
Signer Representing: Signer Is Representing:
12010 NnLOnN Noll Association
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
County of Los Angeles
On April 29, 2014 ,
personally appeared Donna M. (rccu
C MARY SMIT� H
¢ 1111'� OMM. 41919737=
d °�H�.�Y
'c TER) PUBLIC. cALIFORNIA�
¢ 4rt LOS ANG E LES COU NTY
My C,
Pl e Nolan Scat Aboce
before me, 'Mary Smith, Notary Public,
who proved to me on the basis of satisfactory evidence m be
the pe rson03 whose nameM is /are subscribed to the within
instrument and acknowledged to me thathe /shekhev
executed the same in his/her /their authorized capaci yf4s),
and that by h» /her /tkeirsignffiurcr s) on the instrument the
person, or the entity upon behalf of which the person
acted. executed the instrument.
I CC] tile under PENALTY OF PERJURY under the laws of
the Slate of California that the foregoing paragraph is true
and correct.
W 11 NESS my hand and official seal.
S
l
of Notary Public
OPTIONAL
I hough the data below is not required by law, it muy prove duable to persons relying on the document and could prevent
fraudulent reattachment of this farm,
CAPACITY CLAIMED BY SIGNER DESCRIPTION OF ATTACHF,D- DOeLTMENT
❑
INDIVIDUAL
❑
CORPORATE OFFICER
❑
PARTNER(S)
❑ LIMITED
❑
❑
ATTORNEY -IN -FACT
'FRUSTEE(S)
❑
GUARDIAN /CONSERVA"
SIGNER 1, .PRESENTING'
NAME O'. PERSON(S) OR EN'FI'fY(IES)
THE HANOVER INSURANCE COMPANY
MASSACHUSETTS BAY INSURANCE COMPANY
CITIZENS INSURANCE COMPANY OF AMERICA
POWERS OF ATTORNEY
CERTIFIED COPY
KNOW ALL MEN BY THESE PRESENTS. That THE HANOVER INSURANCE COMPANY and MASSACHUSETTS BAY INSURANCE COMPANY, both being
corporations organized and existing under the laws of the State of New Hampshire. and CITIZENS INSURANCE COMPANY OF AMERICA, a corporation
organized and existing under the laws of the State of Michigan, do hereby constitute and appoint
Mary Smith, Steve L. Brookmeyer, Ronald C. Wanglin andfor Donna Green
of Pasadena, CA and each is a true and lawful Attorney(s)-m -fact to sign, execute seal, acknowledge and Schaeffer,
and on Its behalf. and as its act and deed any place within the United Stales. of If the following line be filled In, only within the area therein designated
any and all bonds, recognessncers . undertakings, contracts of Indemnity or other writings obligatory in the nature thereof, as follows:
Any such obligations in the United States, not to exceed Ten Million and NoI100 ($10,000,000) in any single instance
and said companies hereby ratify and confirm all and whatsoever said Attorneyls) -In -fact may lawfully do in the premises by virtue of these presents.
These appointments are made under and by authority of the following Resolution passed by the Board of Directors of said Companies which resolutions
are still in effect.
'RESOLVED, That the President or any Vice President In conjunction with any Vice President be and they are hereby authorized and empowered to appoint
AttOmaysin -star of the Company, In its name and as ho toys to execute and acknowledge for and on its behalf as Surety any and all bontls, recognizances
contracts of Indemnity, waivers of eiurtion and all other writings obligatory in the nature thereof . with power to attach thereto the seal of the Company. Anteroom
wrrhngs so executed by such Atlorneys -in -boot shall be as binding epon the Company as If they boo been duly executed and acknowledged by the regularly
elected officers of the Company in their own proper persons (Adopted October ]. 1981 - The Hanover Insurance Company: Adopted April 14, 1982
Massachusetts Bay Insurance Company, Adopted September 7 2001 - Citizens Insurance Company of America)
IN WITNESS WHEREOF, THE HANOVER INSURANCE COMPANY. MASSACHUSETTS BAY INSURANCE COMPANY and CITIZENS INSURANCE
COMPANY OF AMERICA have caused these presents to be sealed will their respective corporate seals, duly attested crash Vice Presidents,
this 15th day of November 2011. THE HANOVER INSURANCE COMPANY
MASSACHUSETTS BAY INSURANCE COMPANY
CITIZENS INSURANCE COMPANY OF AMERICA
1ffla yp aFAL "�v/ �h,C(.� —'PI -2 Y' ✓; vl''.
Robert TM1Omas Vice Presitlent
i
THE COMMONWEALTH OF MASSACHUSETTS
COUNTY OF WORCESTER ) ss
On this 15th day of November 2011 before me came the above named Vice Presidents of The Hanover Insurance Company, Massachusetts Bay Insurance
Company and Citizens Insurance Company of America. tome personally known to be the Individuals and officers described herein, and acknowledged that the
seals affixed to the preceding instrument are the corporate seals of The Hanover Insurance Company. Massachusetts Bay Insurance Company and Citizens
Insurance Company of America respectively . and that the said corporate seals and their signatures as officers were duty affixed and subscribed to said
instrument by the authority and direction of said Corporations.
A ,M1 BAaeAPAA.BAHLICx
" 1 mor.we
w.m :
,�neraiv, elms
Barbara A. Garlick, Notary Public
My Commission Expires September 21, 2018
I the undersigned Vice President of The Hanover Insurance Company. Massachusetts Bay Insurance Company and Citizens Insurance Company of Amedce,
hereby fa ily that the above and foregoing is a full, true and correct copy of the Original Power of Attorney issued by said Companies, and do hereby further
com y that the said Powers of Attorney are still in force and effect
This Certificate maybe signed by facsimile under and by authority of the following resolution of the Board of Directors of The Hanover Insurance Company,
Massachusetts Bay Insurance Company and Citizens Insurance Company of America.
RESOLVED That any and all Powers of Attemey and Curried Copies of such Powers of AVOmey and certification In respect thereto grantedantlexecuted
by the President or any Ume President in conjunction with any Vice President of the Company shall be binding on the Company to the same extent as it all
signatures therein were manually affixed, even though one or mole of any such signatures thereon may be facsimile. (Adopted October ], 1981 The Hanover Insurance Company Adopted April 14 1982 - Massachusetts Bay Insurance Company Adapted September ], 2001 Citizens Insurance Company 0f
America)
GIVEN under my hand and the seals of said Companies at Worcester Massachusetts. this 29th day of April 2014.
THE HANOVER INSURANCE COMPANY
MASSACHUSETTS BAY INSURANCE COMPANY
CITIZENS INSURANCE COMPANY OF AMERICA
C=lyrn Maryosmn. Vice President
BIDDER: Electro Construction Corp
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 Contractors 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 afterthe deadline for submission 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
hereinafter set forth below.
Subletting or subcontracting of any portion of the Work in excess of one half of one percent
(greaterthan 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
BIDDER: Electro Construction Corp.
23 LIST OF PROPOSED SUBCONTRACTORS (continued)
FD—wl ate N.3 Pages it needed V 11M., addW.O .l sux n"dd. -i
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name:
Address:
NONE
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name:
Address:
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name:
Address:
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name:
Address:
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name:
Address:
CBF -8
BIDDER: Electro Construction Corp.
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. City of Paramount, 16400 Colorado Ave. Paramount CA 90723
Name and Address of Owner
Gregg Stumpf 909 -590 -2626
Name and telephone number of person familiar with project
$450,584.75 Fitness Park renovation 12/02/2013
Contract amount Tvnc of INnrk o -.- r•....,..i..._.
2. City of Los Angeles Dept of Rec & Parks 221 N. Figueroa St. Los Angeles
Name and Address of Owner
Jim Newsom 818 - 679 -1453
Name and telephone number of person familiar with project
$199,539.00 Ken Malloy Harbor Regional Park 5/16/2013
Contract amount mprovemen s Tvoe of work nom r n.�ie.va
3. City of Rosemead, 8838 E. Valley Blvd, Rosemead, CA
Name and Address of Owner
4.
David Montgomery Scott 626 -569 -2161
Name and telephone number of person familiar with project
$56,050.00 Garvey Park Renovation 8/7/2012
Date
and Address
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
CBF -9
BIDDER: Electro Construction Crop.
SECTION 3
NON - COLLUSION AFFIDAVIT
CBF -10
BIDDER: Electro Construction Corp.
CONTRACT BID FORMS
TABLE OF CONTENTS
SECTION1 BID SCHEDULE ....................................................................... ............................... 1
SECTION2 BID DATA FORMS ................................................................... ............................... 5
2.A BID BOND ................................................................................. ............................... 6
2.B LIST OF PROPOSED SUBCONTRACTORS .......................... ............................... 7
SECTION 3 NON - COLLUSION AFFIDAVIT .............................................. ............................... 10
CBF -12
BIDDER: Electra Construction Corp.
NON - COLLUSION AFFIDAVIT
In accordance with Public Contract Code Section 7106, the undersigned, being first duly
swom, 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, orthat 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.
Signature
Rune A. Jensen
Typed or Printed Name
Chief Financial officer
Title
Electra Construction Corp.
Bidder
Subscribed and swom before me PO 14
ti-d
This 3oay of April (Seal)
Attached is the California All- Purpose Acknowledgment
Notary Public in and for
the State of California
My Commission Expires:
CBF -11
........... nuoence ACKNOWLEDGMENT
crva. CODE g 1189
State of California —�
County of Loa Angeles
April 30,2014before me, M. Betty Smith. Notary Public.
On ae.. ima name a,a r,, m m, 01or
a
personally appeared _ Rune A. Jensen n
am,i,l m siu,agel
„a -
nen xssm
who proved to me on the basis of satisfactory
to be the person(y) whose camels) is/aie
evidence
to the within instrument and acknowledged
subscribed
to me that he /shelthey- executed the same in
his /heNNteir authorized capacity(ies), and that by
his/he fheif signature(g) on the instrument the
persomV), or the entity upon behalf of which the
person(`P acted, executed the instrument.
I certify under PENALTY OF PERJURY under the
M. BETTY
laws 01 the Slate Of California that the foregoing
Commission Y 1935369
ara rah is true and correct.
P 9 P
a
N9lary PuGlic - California ;
i Los Angeles County
My Comm. Expires May 7, 2915
WITNESS my hand and official seal.
Signature:L
sua,wmmp wPeene
piewaela " sea nee.a OPTIONAL
Though the in below Is not required
by law, it may prove valuable to persons relying on the document
of this farm to another document
and could prevent fraudulent removal and reattachment
Description of Attached Document
Title or Type of Document: -
— —
Num of Pages: _ -
Document Date'. — —
— — —
Signer(s) Other Than Named Above:
-
Capaci[y(ies) Claimed by Signers)
Signer's Name: — _ —
— Si s Name:
Corporate Officer - Title(s):
Corporate Officer -Title(s) _ -
'Individual
Indivitlual
- P artner - � Limited General r -nor
lnc rat.
' Partner -' Limited General lor�ll mlmo nom
Attorney in Fact
Attorney in Fact
Trustee
_ Trustee
Guardian or Conservato
Guardian or Conservator
- Other: _
I Other: _
Signer Is resenting
Signer Is Representing: J
„a -
nen xssm