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HomeMy WebLinkAboutSeaside Heating and Air Conditioning Inc; 2017-02-27; PWM17-71GSPWM17-71GS CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT This agreement is made on the a?-ttJ.-day of / , 2017, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), d Seaside Heating & Air Conditioning, Inc., a California corporation whose principal place of business is 1359 Rocky Point Dr., Oceanside, CA 92056 (hereinafter called "Contractor"). City and Contractor agree as follows: DESCRIPTION OF WORK. Contractor shall perform all work specified in the Contract documents for the project described by these Contract Documents (hereinafter called "Project"). PROVISIONS OF LABOR AND MATERIALS. Contractor shall provide all labor, materials, tools, equipment, and personnel to perform the work specified by the Contract Documents unless excepted elsewhere in this Contract. CONTRACT DOCUMENTS. The Contract Documents consist of this Contract, exhibits to this Contract, Contractor's Proposal, the Plans and Specifications, the General Provisions, addendum(s) to said Plans and Specifications, and all proper amendments and changes made thereto in accordance with this Contract or the Plans and Specifications, all of which are incorporated herein by this reference. When in conflict, this Contract will supersede terms and conditions in the Contractor's proposal. LABOR. Contractor will employ only skilled workers and abide by all State laws and City of Carlsbad Ordinances governing labor. GUARANTEE. Contractor guarantees all labor and materials furnished and agrees to complete the Project in accordance with directions and subject to inspection approval and acceptance by: Michael O'Brien (City Project Manager) WAGE RATES. The general prevailing rate of wages for each craft or type of worker needed to execute the Contract shall be those as determined by the Director of Industrial Relations pursuant to Sections 1770, 1773 and 1773.1 of the Labor Code. Pursuant to Section 1773.2 of the Labor Code, a current copy of the applicable wage rates is on file in the Office of the City Engineer. Contractor shall not pay less than the said specified prevailing rates of wages to all workers employed by him or her in execution of the Contract. Contractor shall be responsible for insuring compliance with provisions of section 1777.5 of the Labor Code and section 4100 et seq. of the Public Contracts Code, "Subletting and Subcontracting Fair Practices Act." The City Engineer is the City's "duly authorized officer" for the purposes of section 4107 and 4107.5. The provisions of Part 7, Chapter 1, of the Labor Code commencing with section 1720 shall apply to the Contract for work. A contractor or subcontractor shall not be qualified to bid on, be listed in a bid proposal, subject to the requirements of Section 4104 of the Public Contract Code, or engage in the performance of any contract for public work, unless currently registered and qualified to perform public work pursuant to Section 1725.5. This project is subject to compliance monitoring and enforcement by the Department of Industrial Relations. Contractor and any subcontractors shall comply with Section 1776 of the California Labor Code, which generally requires keeping accurate payroll records, verifying and certifying payroll records, and making them available for inspection. Contractor shall require any subcontractors to comply with Section 1776. GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT Page 1 of 8 City Attorney Approved 9/27/2016 PWM17-71GS FALSE CLAIMS. Contractor hereby agrees that any contract claim submitted to the City must be asserted as part of the contract process as set forth in this agreement and not in anticipation of litigation or in conjunction with litigation. Contractor acknowledges that California Government Code sections 12650 et seq., the False Claims Act, provides for civil penalties where a person knowingly submits a false claim to a public entity. These provisions include false claims made with deliberate ignorance of the false information or in reckless disregard of the truth or falsity of the information. The provisions of Carlsbad Municipal Code sections 3.32.025, 3.32.026, 3.32.027 and 3.32.028 pertaining to false claims are incorporated herein by reference. Contractor hereby acknowledges that the filing of a false claim may subject the Contractor to an administrative debarment proceeding wherein the contractor may be prevented from further bidding on public contracts for a period of up to five years and that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor or subcontractor from participating in contract bidding. :? ~ - Signature: C ~~a-;;?.-.._ Print Name: (!' ~ L .... .r {"' "::> -~~'"" lr REQUIRED INSURANCE. The successful contractor shall provide to the City of Carlsbad, a Certification of Commercial General Liability and Property Damage Insurance and a Certificate of Workers' Compensation Insurance indicating coverage in a form approved by the California Insurance Commission. The certificates shall indicate coverage during the period of the contract and must be furnished to the City prior to the start of work. The minimum limits of liability insurance are to be placed with California admitted insurers that have a current Best's Key Rating of not less than "A-:VII"; OR with a surplus line insurer on the State of California's List of Approved Surplus Line Insurers (LASLI) with a rating in the latest Best's Key Rating Guide of at least "A:X''; OR an alien non-admitted insurer listed by the National Association of Insurance Commissioners (NAIC) latest quarterly listings report. Commercial General Liability Insurance of Injuries including accidental death, to any one person in an amount not less than ........ $1 ,000,000 Subject to the same limit for each person on account of one accident in an amount not less than ....... $1,000,000 Property damage insurance in an amount of not less than ........ $1 ,000,000 Automobile Liability Insurance in the amount of $1 ,000,000 combined single limit per accident for bodily injury and property damage. In addition, the auto policy must cover any vehicle used in the performance of the contract, used onsite or offsite, whether owned, non-owned or hired, and whether scheduled or non- scheduled. The automobile insurance certificate must state the coverage is for "any auto" and cannot be limited in any manner. The above policies shall have non-cancellation clauses providing that thirty (30) days written notice shall be given to the City prior to such cancellation. The policies shall name the City of Carlsbad as an additional insured. The full limits available to the named insured shall also be available and applicable to the City as an additional insured. WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY. Workers' Compensation limits as required by the California Labor Code. Workers' Compensation will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. BUSINESS LICENSE. The Contractor and all subcontractors are required to have and maintain a valid City of Carlsbad Business License for the duration of the contract. GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT Page 2 of 8 City Attorney Approved 9/27/2016 PWM17-71GS INDEMNITY. The Contractor shall assume the defense of, pay all expenses of defense, and indemnify and hold harmless the City, and its officers and employees, from all claims, loss, damage, injury and liability of every kind, nature and description, directly or indirectly arising from or in connection with the performance of the Contract or work; or from any failure or alleged failure of Contractor to comply with any applicable law, rules or regulations including those related to safety and health; and from any and all claims, loss, damages, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by the Contract, except for loss or damage caused by the sole or active negligence or willful misconduct of the City. The expenses of defense include all costs and expenses including attorneys' fees for litigation, arbitration, or other dispute resolution method. JURISDICTION. The Contractor agrees and hereby stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this agreement is San Diego County, California. Start Work: Contractor agrees to start within thirty (30) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within thirty-five (35) working days after receipt of Notice to Proceed. CONTRACTOR'S INFORMATION. Seaside Heating & Air Conditioning, Inc. (name of Contractor) 790514 (Contractor's license number) Class C4, C20, C38/ Exp. 1/31/2019 (license class. and exp. date) 1000005586 (DIR registration number) 6/30/2017 (DIR registration exp. date) Ill Ill Ill Ill Ill Ill Ill GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT Page 3 of 8 1359 Rocky Point Dr. (street address) Oceanside, CA 92056 (city/state/zip) 760-643-11 00 (telephone no.) 760-433-3904 (fax no.) cb@seasidehvac.com (e-mail address) City Attorney Approved 9/27/2016 PWM17-71GS AUTHORITY. The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. CONTRACTOR SEASIDE HEATING & AIR CONDITIONING INC., a California corporation By: ~ (print name/title) By: c (sign here) :7 / :-::> (-Vt,-'-r' /,-~ / .:J r.>-/ c r---r C F (:) (print name/title) CITY OF CARLSBAD, a municipal corporation of the State of California By: If required by City, proper notarial acknowledgment of execution by Contractor must be attached . .!f....E. corporation, Agreement must be signed by one corporate officer from each of the following two groups: Group A Chairman, President, or Vice-President Group B Secretary, Assistant Secretary, CFO or Assistant Treasurer Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation. APPROVED AS TO FORM: CELIA A. BREWER, City Attorney BY: fl b..e. e~ Deputy City Attorney GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT Page 4 of 8 City Attorney Approved 9/27/2016 PWM17-71GS EXHIBIT A LISTING OF SUBCONTRACTORS BY GENERAL CONTRACTOR Set forth below is the full name and location of the place of business of each sub-contractor whom the Contractor proposes to subcontract portions of the Project in excess of one-half of one percent of the total bid, and the portion of the Project which will be done by each sub-contractor for each subcontract. NOTE: The Contractor understands that if it fails to specify a sub-contractor for any portion of the Project to be performed under the contract in excess of one-half of one percent of the bid, the contractor shall be deemed to have agreed to perform such portion, and that the Contractor shall not be permitted to sublet or subcontract that portion of the work, except in cases of public emergency or necessity, and then only after a finding, reduced in writing as a public record of the Awarding Authority, setting forth the facts constituting the emergency or necessity in accordance with the provisions of the Subletting and Subcontracting Fair Practices Act (Section 4100 et seq. of the California Public Contract Code). If no subcontractors are to be employed on the project, enter the word "NONE." SUBCONTRACTORS Portion of Project to Business Name and Address DIR Registration License No., %of be Subcontracted No. Classification & Total Ex~iration Date Contract Total% Subcontracted: ------i:i-·7f'J'-~-- The Contractor must perform no less than fifty percent (50%) of the work with its own forces. GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT Page 5 of 8 City Attorney Approved 9/27/2016 PWM17-71GS EXHIBIT B Contractor will replace the aging and inoperable condenser coils in the Carrier Chiller at the Georgina Cole Library located at 1250 Carlsbad Village Dr. in Carlsbad. The replacement of the faulty Carrier Chiller (M#30RBA09059/S#0106Q80692) will be with new Title 24 compliant coils. Scope includes six new Carrier (or equivalent) coils (P#CC-38-3-77.76-18-11-35215) with coating (P#COAT-CC-38-3-44.46.750-18-11-35215), 172 lbs. of refrigerant (R-410a) and two (2) filter drier cores (P#RC4864). Contractor will install and commission chiller to full operating capacity. Cost includes any equipment rentals including crane and torch charges and disposal/recycling of inoperable hardware. The completed repair will return the chiller system to optimum working and controllable condition. JOB QUOTATION ITEM UNIT QTY DESCRIPTION PRICE NO. Replace corroded Carrier condenser coils at the Cole 1 LS 6 Library with new Title 24 compliant Carrier (or equivalent) $29,433.76 coils with coating. TOTAL* $29,433.76 *Includes taxes, fees, expenses and all other costs. GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT Page 6 of 8 City Attorney Approved 9/27/2016 EXHIBIT C LABOR AND MATERIALS BOND Bond 8941 07P PWM17-71GS Premium: $736.00 Premium is for contract term and is subject to adjustment based on final contract price WHEREAS, the City Council of the City of Carlsbad, State of California, has awarded to Seaside Heating & Air Conditioning Inc., (hereinafter designated as the "Principal"), a Contract for: GEORGINA COLE LIBRARY CHILLER COILS REPLACMENT in the City of Carlsbad, in strict conformity with the drawings and specifications, and other Contract Documents now on file in the Office of the City Clerk of the City of Carlsbad and all of which are incorporated herein by this reference. WHEREAS, Principal has executed or is about to execute said Contract and the terms thereof require the furnishing of a bond, providing that if Principal or any of its subcontractors shall fail to pay for any materials, provisions, provender or other supplies or teams used in, upon or about the performance of the work agreed to be done, or for any work or labor done thereon of any kind, the Surety on this bond will pay the same to the extent hereinafter set forth. NOW, THEREFORE, WE, SEASIDE HEATING & AIR CONDITIONING INC., as Principal, (hereinafter designated as the "Contractor"), and Indemnity Company of California as Surety, are held firmly bound unto the City of Carlsbad in the sum of twenty nine thousand four hundred thirty three dollars seventy six cents ($29,433.76), said sum being an amount equal to: One hundred percent (100%) of the total amount payable under the terms of the Contract by the City of Carlsbad, and 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 Contractor or his/her subcontractors fail to pay for any materials, provisions, provender, supplies, or teams used in, upon, for, or about the performance of the work contracted to be done, or for any other work or labor thereon of any kind, consistent with California Civil Code section 9100, or for amounts due under the Unemployment Insurance Code with respect to the work or labor performed under this Contract, or for any amounts required to be deducted, withheld, and paid over to the Employment Development Department from the wages of employees of the contractor and subcontractors pursuant to section 13020 of the Unemployment Insurance Code with respect to the work and labor, that the Surety will pay for the same, and, also, in case suit is brought upon the bond, reasonable attorney's fees, to be fixed by the court consistent with California Civil Code section 9554. This bond shall inure to the benefit of any of the persons named in California Civil Code section 91 00, so as to give a right of action to those persons or their assigns in any suit brought upon the bond. Surety stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract, or to the work to be performed hereunder or the specifications accompanying the same shall affect its obligations on this bond, and it does hereby waive notice of any change, extension of time, alterations or addition to the terms of the contract or to the work or to the specifications. GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT Page 7 of 8 City Attorney Approved 9/27/2016 PWM17-71GS In the event that Contractor is an individual, it is agreed that the death of any such Contractor shall not exonerate the Surety from its obligations under this bond. h-#\ Executed by CONTRACTOR this _----~,::tz,L..---- day of fC~tt nQ , 20___Ll. CONTRACTOR: B~·~----~~~~---------------­-----~-e.trfh here) ~1ivlro1:e 0rin~ (print name here • Pt~iJ~ (print name here) G.f.O · (title and organization of signatory) Executed by SURETY this 8th day of February '20_1L. SURETY: Indemnity Company of California (name of Surety) 17771 Cowan, Ste 100, Irvine, CA 92614 (address of Surety) 800-782-1546 ~S••<ely) (signature of Attorney-in-Fact) Ted Collins, Attorney-in-Fact (printed name of Attorney-in-Fact) (attach corporate resolution showing current power of attorney) (Proper notarial acknowledgment of execution by CONTRACTOR and SURETY must be attached.) (President or vice-president and secretary or assistant secretary must sign for corporations. If only one officer signs, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering that officer to bind the corporation.) APPROVED AS TO FORM: CELIA A. BREWER City Attorney By:~ Deputy City Attorney GEORGINA COLE LIBRARY CHILLER COILS REPLACEMENT Page 8 of 8 City Attorney Approved 9/27/2016 POWER OF ATTORNEY FOR DEVELOPERS SURETY AND INDEMNITY COMPANY INDEMNITY COMPANY OF CALIFORNIA PO Box 19725, IRVINE, CA 92623 (949) 263-3300 KNOW ALL BY THESE PRESENTS that except as expressly limited, DEVELOPERS SURETY AND INDEMNITY COMPANY and INDEMNITY COMPANY OF CALIFORNIA, do each hereby make, constitute and appoint: ***Ted Collins, Leslie Hahn, Jennifer Palmer, Steven R Bonilla, jointly or severally*** as their true and lawful Attorney(s)-in-Fact, to make, execute, deliver and acknowledge, for and on behalf of said corporations, as sureties, bonds, undertakings and contracts of suretyship giving and granting unto said Attorney(s)-in-Fact full power and authority to do and to perform every act necessary, requisite or proper to be done in connection therewith as each of said corporations could do, but reserving to each of said corporations full power of substitution and revocation, and all of the acts of said Attorney(s)-in-Fact, pursuant to these presents, are hereby ratified and confirmed. This Power of Attorney is granted and is signed by facsimile under and by authority of the following resolutions adopted by the respective Boards of Directors of DEVELOPERS SURETY AND INDEMNITY COMPANY and INDEMNITY COMPANY OF CALIFORNIA, effective as of January 1st, 2008. RESOLVED, that a combination of any two of the Chairman of the Board, the President, Executive Vice-President, Senior Vice-President or any Vice President of the corporations be, and that each of them hereby is, authorized to execute this Power of Attorney, qualifying the attorney(s) named in the Power of Attorney to execute, on behalf of the corporations, bonds, undertakings and contracts of suretyship; and that the Secretary or any Assistant Secretary of either of the corporations be, and each of them hereby is, authorized to attest the execution of any such Power of Attorney; RESOLVED, FURTHER, that the signatures of such officers may be affixed to any such Power of Attorney or to any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures shall be valid and binding upon the corporations when so affixed and in the future with respect to any bond, undertaking or contract of suretyship to which it is attached. IN WITNESS WHEREOF, DEVELOPERS SURETY AND INDEMNITY COMPANY and INDEMNITY COMPANY OF CALIFORNIA have severally caused these presents to be signed by their respective officers and attested by their respective Secretary or Assistant Secretary this 18th day of April, 2016. By:~~ Daniel Young, Senior Vice-President By: Mark Lansdon, Vice-President 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 Orange On ____ _,_A""pr"'il_,_1,8,_,2""0-"16,__ ____ before me, ____________ __,L'C'u"'ci'C'IIee.cR_,a':.ly.ccm"'o"'nd":-, .;:N~ota,ry':'-'-P:O:u:"bl,ic _____________ _ Date Here Insert Name and Title of the OffiCer personally appeared --------------------"D00an"'"ie,I...:Y:::;ou7-'n"'-g-:'a':"nd=:-'M:::'a"'r":k.:CLa"'n"'s"'do""n'---------------------- Name(s) of Signer(s) Place Notary Seal Above 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(ies), 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. I certify under PENAL TV OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. CERTIFICATE The undersigned, as Secretary or Assistant Secretary of DEVELOPERS SURETY AND INDEMNITY COMPANY or INDEMNITY COMPANY OF CALIFORNIA does hereby certify that the foregoing Power of Attorney remains in full force and has not been revoked and, furthermore, that the provisions of the resolutions of the respective Boards of Directors of said corporations set forth in the Power of Attorney are in force as of the date of this Certificate. This Certificate is executed in the City of Irvine, California, this 8th day of February ' 2017 ID-1380 (Rev. 04/16) CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 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 Diego 0 February 8, 2017 b f J. Palmer, Notary Public n -----'---'------e ore me, -----------'------------ Date Here Insert Name and Title of the Officer personally appeared _________ T_e_d_C_o_l_li_n_s _______________ _ Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person~ whose name~ is/a.Fe subscribed to the within instrument and acknowledged to me that he/eAel~llley executed the same in hisll:l8Ffott=leir authorized capacityQeS}, and that by his/t:le11'tl •eit signature.£s)' on the instrument the person~. or the entity upon behalf of which the person(.ij' acted, executed the instrument. ~ •. ··-'· • J. PALMER ~ ii: .·· · • · CommisSion No. 2146155 ~ . · . NOTARY PUBLIC-CALIFORNIA ~ · . SAN DIEGO COUNTY ~ ~ • Commission Expires March 231 ~ ~ Place Notary Seal Above 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. -----------------------------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: _______ _ Number of Pages: Signer(s) Other Than Named Above:------------- Capacity(ies) Claimed by Signer(s) Signer's Name: -------------Signer's Name: ____________ _ Corporate Officer -Title{s): ______ _ ._ Corporate Officer -Title(s): ______ _ C:: Partner -Limited D General Partner -. ' Limited -General L.c Individual I ; Attorney in Fact ~--Individual · • Attorney in Fact ~Trustee . Guardian or Conservator ::Trustee =~Guardian or Conservator Other: ______________ ___ ._: Other: --------------Signer Is Representing: _________ _ Signer Is Representing: __ _ ".,'G(,'<X,;C<,;<.:<~'<-X;<X)<~X~X:<-'C<."-:.VX;...,x:.y~'v()<X;Cv'C<,'C<;,'C<,'CV'<.:.<,;<.:i()<.X,'<.X;<A_'<:;(;.'C<,'<;{,'Co(,.'<.Xv'<"'-''<'<VXO<,'C<,'<.X)<.::<;<:X..'<-'<.-'C()<.l(;,'<X.'<.l(,.'<.'i(.'C<,'<.l(;,'< ©2014 National Notary Association· www.NationaiNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 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. who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) ..jefare subscribed to the within instrument and acknowledged to me that ~/they executed the same in -flis,'i"ler/their authorized capacity(ies), and that by ~/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. ,.~~;.:;::~1 ;;; COMM. 12152386 ilt ;r NOTARY PU8LJC.CALIFORN ~ l .· SAN DIEGO COUNTY My eomm. &pns June ... 2020 I SCCCC CCUUCCCCCSSSSUU CCCL Place Notary Sea/ Above I certify under PENAL TV 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 cJ {2 Q. Signature of Notary Public ----------------------------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 Docume'}t ~A_,_,: I " r _,. I J Title or Type of Document: Uti20WS ~ )Vtti{'t'C?tlta !i.YaDocument Date: !'f~ II Number of Pages: Signer(s) Other Than Named Above: __________ _ Capacity(ies) Clai d by Sign (s Signer's Name: -"""-1"f-><;f-'-'-'-'t '-<--~c-"'~-'T------,~-:t;;o­ ~ Corporate Officer -Title(s): ---+~~~~c!__­ LJ Partner -! Limited : 1 General 1-llndividual ! Attorney in Fact ~--! Trustee I I Guardian or Conservator [~Other:---·------------ Signer Is Representing: ________ _ Signer's Name: vM~~~ ~[ U::tr ')(Corporate Officer -Title(s): c.f.o A I l Partner -I I Limited , General I I Individual ! I Attorney in Fact r 1 Trustee · Guardian or Conservator i 1 Other: _____________ _ Signer Is Representing: ________ _ ©2014 National Notary Association· www.NationaiNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907