Sales Tax 09-CS110627 CCI Surety, Inc.
Status Report
To Be Completed By Obligee
PRINCIPAL: RKM Utility Services, Inc.
BOND NO: sb001000670 Bond Amount:$1,122,180.00
Original Contract Amount:$1,122,180.00
TO: City of Coppell
255 Parkway Blvd. IT IS UNDERSTOOD THAT THE INFORMATION
CONTAINED HEREIN IS FURNISHED AS A MATTER OF
COURTESY FOR THE CONFIDENTIAL USE OF THE
Coppell, TX 75019 SURETY AND IS MERELY AN EXPRESSION OF
OPINION. IT IS ALSO AGREED THAT IN FURNISHING
THIS INFORMATION, NO GUARANTY OR WARRANTY
OF ACCURACY OR CORRECTINESS IS MADE AND NO
RESPONSIBILITY IS ASSUMED AS A RESULT OF
RELIANCE BY THE SURETY WHETHER SUCH
INFORMATION IS FURNISHED BY THE OWNER OR BY
AN ARCHITECT OR ENGINEER AS THE AGENT OF THE
DESCRIPTION: nWNFR
Tax 2009 Street Replacement (S. Heartz Road, Dobecka Drive & Clear Creek Lane)- Project No. Tax 2009,
Coppell, TX
Obligee: City of Coppell
Construction Capital, Inc. is the bonding agent on the above bond. We will appreciate your cooperation in providing
the information requested below. Please return this form to us so that we may have current status information on the
captioned job. Thank you for your assistance. /
Please Complete One Section Only. Date: c "2141/
IF THE CONTRACT HAS BEEN COMPLETED
1 . What was the completion date?
Date of acceptance: 4)-4,G_- 3 0, ZQ /f'
2. What was the final contract price? 'l/ /61,91 , 1012, e-70
Has the full amount been paid? IffS-
3. Was the work satisfactory? V1$
4. Have all labor & material bills been paid? SE€ ,4 HHSt /
white Consfra-e ton Supply
II. If The Contract Has Not Been Completed:
1 . What percentage of work has been completed to date? -
2. Total amount paid to Contractor to date?
3. What is amount of retainage? _
4. What is the anticipated date of completion?
5. Is the contractor paying labor and material bills?
6. Is the work progressing satisfactory? _
7. Is the above contract amount stated correctly? (Y/N) If not,what is the correct contract price?
By-Signature (Representing)
• Date: ,/ 7-7 7
lc/NIP �`t`l4) "• 1 �j
By-(type or print name) Phone: ( �6 6/ 9) 5`')g-
Remarks:
Please fax to (763)512-0430 or mail to 1710 N. Douglas Drive, Suite 110, Golden Valley,MN 55422 Thank you.
STATE OF TEXAS
NOTICE TO PRIME CONTRACTOR AND
BONDING COMPANY
GOVERNMENT PROJECT
7196 9002 4000 1415 0221
Bildrs No: 3280231
CITY OF COPPELL RETURN RECEIPT
ENGINEERING DEPT 06/15/2011
255 PKWY BLVD Bildrs No. 3280231
COPPELL TX 76019-9478 7196 9002 4000 1415 0221
RE: 92014034- GENERAL BUILDING MATERIALS
2009 STREET REPLACEMENT, SANDY LAKE & HEARTZ, COPPELL, TX 75019
Notice is hereby given pursuant to Tex. Govt. Code §2253.041 that HD SUPPLY/WHITE CAP CONSTRUCTION SUPPLY
has furnished materials or labor consisting of GENERAL BUILDING MATERIALS and related materials or labor pursuant to an
agreement with RKM UTILITY SERVICES INC, 92014000, 1171, 1544 VALWOOD PKWY STE#100, CARROLLTON TX
75006 for the above-referenced job for CITY OF COPPELL, 255 PKWY BLVD, COPPELL TX 76019-9478, ENGINEERING
DEPT. The materials were delivered and installed during the month(s) of Mar 11. To date, the amount due and unpaid for such
labor and/or materials is $7,073.67, which amount is now claimed by this notice.
Attached hereto is a sworn statement of account, which is made a part of this claim for all purposes. A copy of the invoices
that represent the materials delivered to the project that have not been paid for, may also be attached.
HD SUPPLY/WHITE CAP CONSTRUCTION SUPPLY
9950 S 134TH ST
OMAHA, NE 68138
800-209-3526
P71/
Title:Title: BICA Representative
06/15/2011
BICA 1-800 722-2422
Owner: CITY OF COPPELL, 255 PKWY BLVD, COPPELL TX 76019-9478,ENGINEERING DEPT
Orig Contr: RKM UTILITY SERVICES INC, 1544 VALWOOD PKWY #100,CARROLLTON TX 75006
Surety: ULLICO CASUALTY COMPANY, 1625 EYE STREET NW, WASHINGTON DC 20006,Bond# SB001000670, BOND DEPT
Customer: RKM UTILITY SERVICES INC, 92014000, 1171, 1544 VALWOOD PKWY STE#100, CARROLLTON TX 75006
Job No: 92014034
Form Rev: 12/06 VP
06/15/2011
STATE OF TEXAS
STATE GOVERNMENT FORM
Sworn Statement of Account
THE STATE OF CALIFORNIA
COUNTY OF LOS ANGELES
BEFORE ME THE UNDERSIGNED AUTHORITY on this day personally appeared VICTOR
RODARTE who upon his/her oath,deposed and stated the following:
1) My name is VICTOR RODARTE. I am the Agent of the claimant named in the foregoing Notice, and
that I am informed and believe the facts herein to be true, and, on that ground, allege that the facts stated in
the foregoing Notice are true.
2) In accordance with a contract with RKM UTILITY SERVICES INC,92014000, 1171, 1544
VALWOOD PKWY STE#100,CARROLLTON TX 75006,HD SUPPLY/WHITE CAP
CONSTRUCTION SUPPLY has furnished GENERAL BUILDING MATERIALS in connection with
the building of the 2009 STREET REPLACEMENT,SANDY LAKE&HEARTZ, COPPELL,TX
75019.
3) The amount due and unpaid by RKM UTILITY SERVICES INC,92014000, 1171 for such materials,
after allowing for all gust and lawful offsets,payments,and credits known to me is$7,073.67, for which a
claim is hereby// :•-. Tha7ount is just and correct.
HD SUPPL;'/WHI �CAP;CONT RUCTION SUPPLY
By: A'
Or Agent
9950 S 134TH ST
OMAHA,NE 68138
800-209-3526
SUBSCRIBED AND SWORN TO BEFORE me on this the 15 day of June,2011.
r./...;-: g-,,;,-, JENNY SIELES r
A4414-1.
ti Commission # 1777347 A VOTARY C�rI.LIC
- ,. y;r,,
Z ; Notary Public - California
:, • Los Angeles County z.
ilrry Comm.F res Nov 28,20l l
Bildrs No:3280231