SW0801-CS110518 Final Bills Paid Affidavit
by Contractor
BEFORE ME, the undersigned authority, personally appeared (hereinafter referred to as
"Contractor"), known to me to be a credible person, and after being by me duly sworn, upon oath stated and affirmed that:
"My name is )4466 b(ivOietr and I am the fibiloif p p/e/e,of 3D4 o
hereafter sometimes referred to in this affidavit as "Contractor ". Contractor's business address is /
The undersigned Contractor has personal knowledge of the facts stated herein and
has full authority to make the agreements in this affidavit on behalf of Contractor.
Pursuant to and in accordance with a written construction contract between3p 1 ,4 dD 6j :Contractor, and
4 , 0 -6 ' 0 r , Owner /Administrator, Contractor furnished materials and labor for the construction,
renov ion, or repair of improvements located on or relating to project known as/NM/it aP S/DI�c�J9 - '1 ocated
at DEi r2,ti , J O , City of 617 OiDbZL_ , , 6 ( . , s County, Texas, legally
described in Exhibit "A" attached hereto and made a part hereof for al purposes the "Property"). All work provided
for under said written construction contract, together with all changes and supplements thereto, has been fully
completed in accordance with the terms and provisions thereof.
Contractor has paid each of its subcontractors, laborers, suppliers and materialmen in full for all labor and materials
provided to Contractor for or in connection with the construction, renovation, or repair of improvements on or relating to
the subject Property, or any portion thereof, excepting only the amounts owed for the following specified bills to the
persons identified below. Contractor warrants and represents that the following specified bills will be paid to Contractor
by Owner /Administrator in reliance on this Final Bills Paid Affidavit:
Name of Payee Address Telephone No. Amount Owed
N/L
Other than the above specified bills owed to the above referenced persons, Contractor is not aware of any unpaid bills,
claims, demands, or causes of action by any of its subcontractors, laborers, suppliers, or materialmen for or in connection
with the furnishing of labor or materials, or both, for the construction, renovation, or repair of improvements located on or
related to the subject Property.
In consideration of the funds paid to Contractor by Owner /Administrator and by Lender on behalf of Owner /Administrator
in reliance on this affidavit, Contractor waives and releases all of Contractor's statutory and constitutional mechanic's lien
rights connected with the construction of the Project, conditioned on the actual payment or collection if payment is made
by check or draft.
Contractor further understand that this Final Bills Paid Affidavit is being given pursuant to and in accordance with
Sections 53.085 and 53.259 of the Texas Property Code and that the intentional, knowing, or reckless making of a false or
misleading statement in this Affidavit constitutes an offense under said Section and is a Class A misdemeanor.
Contractor hereby indemnifies and holds harmless Owner /Administrator from any and all claims, demands or causes of
action, and any costs, expenses, and attorney's fees incurred in connection therewith, arising from or connected with, the
statements and representations contained herein."
Form 16 — Final Bills Paid Affidavit Page 1 of 3
May 1, 2009
EXECUTED this I a ]day of ,*.fY , 20 / ( .
•
c3.0 Iaie'✓ /A/6 irz & , 7A. (!s
[Name of Contractor Company]
By: FN
Printed N e: tfpG fj�{yO,
Title: /nV4t#o
Notary's Acknowledgement
Before me, the undersigned authority, on this day personally appeared
who first being duly sworn by me to be the person whose name is subscribed to the foregoing Final Bills Paid Affidavit,
acknowledged that he /she has the authority to make this Final Bills Paid Affidavit, and further acknowledged to me that he/
she executed the same for the purpose and consideration therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE on e . ay of , 20 / ( .
(Seal)
.40 ` n,
EDWIN M ADORNO o . Pus ic, State o Texas
w My C omm Sep tem iss r io25 n Expires 201 My commission expires �" Z Z C
be , 1 Y p
91 F
Form 16 — Final Bills Paid Affidavit Page 2 of 3
May 1, 2009
Bond No. CNB-11944-09
CONSENT OF OWNER El
ARCHITECT
SURETY COMPANY CONTRACTOR 0
TO FINAL PAYMENT SURETY
OTHER 0
AIA DOCUMENT G707
PROJECT: Denton Tap Sidewalk Infill
(name, address) Coppell, TX
TO (Owner)
City of Coppell ARCHITECT'S PROJECT NO:
255 Parkway CONTRACT FOR Project No. SVV08-01
Coppell, TX 75019 Denton Tap Sidewalk lnfill
1 CONTRACT DATE: 09/28/2010
CONTRACTOR: 3D Paving and Contracting, LLC
PO Box 1898
Coppell, TX 75019
In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above, the
there insert name and address of Surety Company)
Insurors Indemnity Company, PO Box 2683, Waco, TX 76702 SURETY COMPANY,
on bond of Mere insert name and address of Contractor)
3D Paving and Contracting, LLC
PO Box 1898 , CONTRACTOR,
Coppell, TX 75019
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 (here insert name .111d address of owner)
City of Coppell
255 Parkway , OWNER,
Coppell, TX 75019
as set forth in the said Surety Company's bond.
IN WITNESS WHEREOF,
the Surety Company has hereunto set its hand this 11th day of May, 2011
lnsurors Indemnity Company —
Surety Company
Signatureof t zed epresentative
Attest:
(Seal): Attorne y - act Jay Jordan
Title
NOTE: This form is to be used as a companion document to AIA DOCUMENT G706, CONTRACTOR'S AFFIDAVIT OF PAYMENT OF DEBTS AND
CLAIMS, Current Edition
AIA DOCUMENT C7.7 • CONSENT OF SURETY COMPANY TO FINAL PAYMENT • APRIL 1970 enlitoN • MAO ONE PACE
1970 • THE AMERICAN INSTITUTE OF ARCH:TECTS, 1735 NEW YORK AVE., NW, WASHINGTON, D.C. 20006
-
T»����Y�T���T��
�[�u����^�c^^� il>TPEMNITY
POWER OF ATTORNEY of INSURORS INDEMNITY COMPANY
Waco, Texas
KNOW ALL PERSONS BY THESE PRESENTS: Number: CNB-11944-09
That |NSURDR8 INDEMNITY COMPANY, Waco, Texeo, organized and existing under the laws of the State of
Texme, and authorized and licensed to do business in the State of Texas and the United States of America, does
hereby make, consttute and appoint
Jay Jordan of the City of Rockwall, State of Texas
as Attorney in Foot, with full power and authority hereby conferred upon him to aign, execute, acknowledge and
deliver for and on its behalf as Surety and as its act and daed, all of the following classes of document, to-wit:
Indemnity Surety and Undertakings that may be desired by contract, or may be given in any action
or proceeding in any court of law or equity; Indemnity in all cases where indemnity may be lawfully
given and with full power and authority to execute consents and waivers to mochfy or change or
extend any bond or document executed for this Cornpany.
INSURORS INDEMNITY MPANY
Tammy Tiepermiand TNum4s Chaae.Jr.Cha|nna nd CEO
State of Texa
County of McLennan
On the 8th day of Juty, 2009, before me a Notary Public in the State ot' Texas, personafly appeared Thomas G. Chase,
Jr. and Tammy Tieperman, who bei by me duly sworn, acknowtedged that they executed the above Power of Attorn in their
ities as Chairman and Chief Executive Officer, and Corporate 0euna*zry, respectively, of|oavmm Indemnity Company,
and acknowtedged said Power of Attorney to be the votuntary act an deed of the Cmnpony.
/' `
SHERRI WHITEHOUSE
�" or/ „r
Notary Pubhc State of
STATE OF TEXAS
My Comm Exp 05/21/2013
insunonm indemnity Company certifies that this Power of Attorney is granted under and by authority of the
following resolutions of the Company adopted by the Board of Directors on July 8, 2009:
RESOLVED, that all bonds, undertakings, contracts or other obligations may be executed in the name of the Company
by persons appointed as Attorney in Fact pursuant to a Power of Attorney issued in accordance with these Resolutions Said
Power of Attorney shall be executed in the name and on behalf of the Company either by the Chairman and CEO or the
Pmsiden\, under their respective designation. The signature of such officer and the seal of the Company may be affixed by
facsimile to any Power af Attorney, mvd, unless subsequently revoked and subject to any limitation set forth |ham)n, any such
Power of Attorney or certificate bearing such facsimile signature and seal shall be valid and binding upon the Company and any
such power so executed and certified by facsimile signature and seal shall be valid and binding upon the Company with respect
to any bond or undertaking to which it is validly attached.
RESOLVED, that Attorneys in Fact shall have the power and amdhohty, subject to the terms and limitations of the
Power of Attorney issued to them, to execute and deliver on behalf of the Company and to attach the seal of the Company to
any and alt bonds and undertakings, and ariy such instrument executed by such AttomeywinFadshaUbeb|ndingupomtb e
Company as if signed by an Executive Officer and sealed and attested to by the Secretary or Assistant Secretary of the
Company.
1, Tammy Tieperman, Secretary of |naumro Indemnity Compeny, do hereby certify that the foregoing is a true excerpt
from the Resolutions of the said Company as adopted by its Board of Directors on July 8, 2009, and that this Resolution is in full
force and effect. I certify that the foregoing Power of Attorney is in full force and effect and has not been revoked.
In Witness Whereof, I have set my hand and the seal of INSURORS INDEMNITY COMPANY on this 11th
day of 2O11 '
'
~- \
.".,,.y Tiepe:ritian, Secretary'
NOTE: IF YOU HAVE ANY QUESTION REGARDING THE VALIDITY OR WORDINGOF THIS POWER OF ATTORNEY
PLEASE CALL 00O9337444OR WRITE T3UG8TF\[\ BOX 2883.VVACO. TEXAS 767B2-2O83OR EMAIL U84J
CDNF|RMAT0N