HomeMy WebLinkAboutNissho of California; 2014-04-03; PKR530Tracking #:
CITY OF CARLSBAD
MINOR PUBLIC WORKS CONTRACT
CANNON LAKE PARK FRONTAGE IMPROVEMENTS; CONT. NO. PKRC530
This agreement is made on the 3> day of rXpVfX^ , 2oJ^, by the
City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and Nissho of California,
Inc. whose principal place of business is 1902 South Santa Fe Avenue, Vista, CA 92083 (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.
CALIFORNIA REGIONAL WATER QUALITY CONTROL BOARD, SAN DIEGO REGION.
A. Contractor shall not allow any discharges from the construction site, which may have an adverse
effect on receiving waters of the United States.
B. Contractor shall not allow any groundwater extraction water to be discharged from construction site
except in full compliance with the General Waste Discharge Requirements for Ground Water
Extraction and Similar Discharges from Construction and Remediation Projects (Order No. 96-41)
adopted by the Regional Board. Prior to submitting Bid, Contractor shall obtain a copy of said Order
No. 96-41 and review all compliance requirements therein, including monitoring, testing, and
reporting.
C. In the event of conflict between the Contract and Permit requirements, the most stringent shall
prevail. All permit requirements shall be satisfied by Contractor and accepted by all issuing
agencies, and the Owner before project will be accepted and a Notice of Completion filed.
D. Contractor shall, at his own expense, procure any additional permits, certificates, and licenses
required of him by law for the execution of the work. He shall comply with all Federal, State and
local laws, ordinances or rules and regulations relating to the performance of said work.
E. The Contractor shall incorporate and comply with all applicable Best Management Practices
(BMPs) during the completion of this agreement. All work must be in compliance with the most
current San Diego Regional Water Quality Control Board (RWQCB) permit, Carlsbad Municipal
code and the City of Carlsbad Jurisdictional Urban Runoff Management Plan (JURMP)
incorporated herein by reference.
F. The Contractor shall indicate in his submittals methods of compliance, equipment utilized to
insure compliance, training of staff and expenence in compliance with environmental regulations.
If in the opinion of the project manager, the Contractor is not in compliance with this provision,
CANNON LAKE PARK FRONTAGE
IMPROVEMENTS,
CONT. NO. PKRC530 Page 1 of 6 City Attorney Approved
2/7/13
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CITY reserves the right to implement BMP's to the maximum extent practical, and deduct
payment due or back charge the Contractor for implementation with a 15% markup for
administration and overhead.
GUARANTEE. Contractor guarantees all labor and matenals furnished and agrees to complete the
Project in accordance with directions and subject to inspection approval and acceptance by Kyle
Lancaster
(City Project Manager)
PREVAILING WAGES NOT REQUIRED. The City of Carlsbad is a Charter City Carlsbad Municipal
Code Section 3 28.130 supersedes the provisions of the California Labor Code when the public work is
not a statewide concern Payment of prevailing wages is at Contractor's discretion
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 ofthe truth or falsity ofthe 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 junsdiction is grounds for
the City of Carlsbad to disqualify the Contractor or subcontractor from participating in contract bidding.
Signature
Print Name UClh'^ ^- bo)leH?n
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 Califomia Insurance
Commission. The certificates shall indicate coverage dunng 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 insurers that have. (1) a rating in the most recent Best's Key Rating Guide of at least A- V and (2) are
admitted and authonzed to transact the business of insurance in the State of California by the Insurance
Commissioner
Commercial General Liability Insurance of Injuries mcluding accidental death, to any one person in an
amount not less than ..$500,000
Subject to the same limit for each person on account of one accident in an amount not less than
. . $500,000
Property damage insurance in an amount of not less than . ..$100,000
Automobile Liability Insurance in the amount of $100,000 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
CANNON LAKE PARK FRONTAGE
IMPROVEMENTS,
CONT NO PKRC530 Page 2 of 6 City Attorney Approved
2/7/13
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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 pnor to such cancellation.
The policies shall name the City of Carlsbad as an additional insured
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 descnption, 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 mcluding 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 junsdiction 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 10 working days after receipt of Notice to Proceed.
Completion Contractor agrees to complete work within 25 working days after receipt of Notice to
Proceed.
CONTRACTOR'S INFORMATION.
Nissho of California, Inc 1902 South Santa Fe Avenue
(name of Contractor)
#598372
(Contractor's license number)
(license class, and exp date)
W
W
W
W
W
W
(street address)
Vista / CA / 92083
(city/state/zip)
(760) 727-9719
(telephone no)
(760) 727-8706
(fax no)
tom@nisshoca.com
(e-mail address)
CANNON LAKE PARK FRONTAGE
IMPROVEMENTS;
CONT NO PKRC530
2/7/13
Page 3 of 6 City Attorney Approved
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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, nght and actual authority to bind
Contractor to the terms and conditions of this Agreement.
CONTRACTOR CITY OF CARLSBAD, a municipal corporation
of the State of California
(sign here) /i i v? ' Depanment Director
Cp.cili^ & t)0\\pM - cmft'G IkrjSpS'flWiA, as authorized by the City Manager
(pnnt name/title) J chris Hazeltine ^""^'S^lo''.
By: n ATTEST: ^ iS-Z^^'i^Z^-^^.
(sign here) mRBARA ENGLE^
tt « 0^ City Clerk \ C'X'"-? o-^^"^
\ (pnnt name/title)
If required by City, proper notanal acknowledgment of execution by Contractor must be attached. If a
corporation. Agreement must be signed by one corporate officer from each of the following two groups
Group A Group B
Chairman, Secretary,
President, or Assistant Secretary,
Vice-President CFO or Assistant Treasurer
Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under
corporate seal empowenng the officer(s) signing to bind the corporation.
FORM
:R, City Attorney_
CANNON LAKE PARK FRONTAGE
IMPROVEMENTS,
CONT NO. PKRC530 Page 4 of 6 City Attorney Approved
2/7/13
Trackings:
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
be Subcontracted
Business Name and Address License No.,
Classification &
Expiration Date
%of
Total
Contract
Total % Subcontracted: 3X?
CANNON LAKE PARK FRONTAGE
IMPROVEMENTS,
CONT NO PKRC530
2/7/13
Page 5 of 6 City Attorney Approved
EXHIBIT B
JOB QUOTATION
Tracking #:
IP
illTEM
'if myi
UNIT QTY DESCRIPTION PRICE
1 LS ' 1 Demolition, Grading and Labor $2,926 00
2 LS 1 Fence Installation $5,053 30
3 LS 1 New Irngation System $8,297 04
4 LS 1 Planting & Mulching $8,593.00
TOTAL* $24,869.34
*lncludes taxes, fees, expenses and all other costs.
CANNON LAKE PARK FRONTAGE
IMPROVEMENTS,
CONT NO PKRC530
2/7/13
Page 6 of 6 City Attorney Approved
NISSHO OF CALIFORNIA INC
1902 South Santa Fe Avenue Vista California 92083 Phone 760 727 9719 Fax 760 727 8706
License #598372 ^^^^^^^
NISSHO JOI # CLIENT P.O. #
WORK ORDER Proposal Summary LC 1
COC Roadside
Project Name
(760) 434 2922
Client Phone #
paui harnson@carisbadca gov
email
City of Carlsbad
Client Name
Authonzed by (Sign) Date
^ ^ ^ Nissho Internal Only ^
(Maintenance Department)
Paul Harnson Gregg Fonseca 1 314
Authorized by (Pnnt) Project Manager (Print) /\ C
/ AJ
ate
Sales Rep Approval (Sign) Mgmt Approval
DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Cannon Lake Park Frontage Improvements to include CONTACTING DIG ALERT to mark all existing underground
utility lines the demolition of exisitng FENCES, removal of waste concrete plant matenal and debris from side edge to
new Fence line (15 feet from Sidevi/alk Edge) Laboratory Soil Testing Fence & Gate Installation Installation of
an Irngation System and City Inspection of the Irrigation System Approval of 24 Box Trees by City Lists of Fertilizer and
Supplying Nurseries planting of new trees and perennials MULCHING of site and installation of YELLOW DIAMOND
Reflector Sign on new fence
MATERIALS ^ ^ ""^ QTY PRICE / TOTAL
Demolition Grading and Labor 1 $2 926 00 $ 2 926 00
$
Fence Installation 1 $5 053 30 $ 5 053 30
$
New Irngation System 1 $ 8 297 04 $ 8 297 04
$
Planting & Mulching 1 $ 8 593 00 $ 8 593 00
LABOR < HRS RATE TOTAL
Included Above $
$
$
$
GRAND TOTAL $ 24 869 34
THESE SIGNATURES BELOW CERTIFY THAT THE AREAS HAVE BEEN THOROUGHLY INSPECTED BY THE UNDERSIGNED
REPRESENTATIVE IT HAS BEEN DETERMINED THAT THE INSTALLATION IS IN ACCORDANCE WITH THE PLANS OR THE AGREED UPON
SPECIFICATIONS BY THE DEVELOPER/CLIENT AND NISSHO OF CALIFORNIA INC
Nissho of California
Representative PnnI Sign Date
Client
Representative Print Sign Date
NISSHO OF CALIFORNIA INC
1902 South Santa Fe Avenue Vista California 92083 Phone 780 727 9719 Fax 760 727 8706
License #598372
WORK ORDER
NISSHO JOB # CLIENT P.O. #
Proposal LC 5 Demolition/Grading
ity of Carlsbad Cannon Parkwa
Project Name
(760) 434 2922 _
City of Carlsbad
Client Name
Kyle Lancaster
Client Phone #
Kvie LancasteriioS.cartsbadca gov _
Authorized by (Print)
E Mail ^uthonzed by (Sign Date
Nissho Internal Only
(Maintenance Department)
Gregg Fonseca
Project Manager (Pnnt)
Sales Rep Approval (Sign) Mgmt Approval
DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Cannon Rd South side due West of Rail Road Tracks
Dig Alert Demolition of Existing Fences Trash and old plant removal Site Grading Instal new
Irrigation system Instal New Fence Instal New plant material MULCH site
MATERIALS * ^QTY PRICE TOTAL ^
Dig Alert $
Soil Testing with Willis Labs per City Spec 4 $ 183 00 $ 732 00
Bobcat 1 $ 250 00 $ 250 00
Drop Off/Pick Up 2 $ 75 00 $ 150 00
Dump Fees (per ton) 10 $ 80 00 $ 800 00
Dumpster (dropoff/pickup) 2 $ 189 00 $ 378 00
$
$
$
$
SOIL TEST RESULTS REQUIRED INSPECTION BEFORE START OF $
PROJECT $
$
$
LABOR „ ^ HRS RATE TOTAL
Laborer (demo) 8 $ 23 00 $ 184 00
Operator (demo) 16 $ 27 00 $ 432 00
$
1 GRAND TOTAL $ 2 926 00
THESE SIGNATURES BELOW CERTIFY THAT THE AREAS HAVE BEEN THOROUGHLY INSPECTED BYTHE UNDERSIGNED
REPRESENTATIVE IT HAS BEEN DETERMINED THAT THE INSTALLATION IS IN ACCORDANCE WITH THE PLANS OR THE AGREED UPON
SPECIFICATIONS BY THE DEVELOPER/CLIENT AND NISSHO OF CALIFORNIA INC
Nissho of California
Representative
Client
Representative
Pnnt Sign Date
Print Sign Date
NISSHO OF CALIFORNIA INC
1902 South Santa Fe Avenue Vista California 92083 Phone 760 727 9719 Fax 760 727 8706
License #598372
NISSHO JOB * CLIENT P.O. #
WORK ORDER Proposal LC 5 Fence
ity of Carlsbad Cannon Parkwa
Project Name
(760) 434 2922 _
Client Phone #
Kvle Lancasterigicarlsbadca gov
City of Carlsbad
Client Name
Kyle Lancaster
Authorized by (Pnnt)
E Mail Authorized by (Sign Date
Nissho Internal Only
(Maintenance Department)
Gregg Fonseca
Project Manager (Pnnt)
Sales Rep Approval (Sign) Mgmtf\pproval
DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Cannon Rd South side due West of Rail Road Tracks
Dig Alert Demolition of Existing Fences Trash and old plant removal Site Grading Instal new
Irrigation system Instal New Fence Instal New plant material MULCH site
MATERIALS ^ ^ QTY PRICE -+TOTAL
$
240 Linear feet of 2 rail Peeler Pole fencmg+Gate $
$
poles (Rails) 3 diameter pressure treated 8 long $
Posts 4 diamter Douglas Fir beveled tops (45 degree) 4 from grade to top $
Total Expense 1 $ 4 876 30 $ 4 876 30
Yellow Diamond Reflector Sign 1 $ 177 00 $ 177 00
$
$
$
$
$
$
$
LABOR ^_^v, ^'^'^S* J*. HRS RATE TOTAL
Laborer $
Foreman $
$
GRAND TOTAL $ 5 053 30
THESE SIGNATURES BELOW CERTIFY THAT THE AREAS HAVE BEEN THOROUGHLY INSPECTED BY THE UNDERSIGNED
REPRESENTATIVE IT HAS BEEN DETERMINED THAT THE INSTALU\TION IS IN ACCORDANCE WITH THE PLANS OR THE AGREED UPON
SPECIFICATIONS BY THE DEVELOPER/CLIENT AND NISSHO OF CALIFORNIA INC
Nissho of California
Representative
Client
Representative
Print Sign Date
Print Sign Date
NISSHO OF CAUFORNIA INC
1902 South Santa Fe Avenue Vista California 92083 Phone 760 727 9719 Fax 760 727 8706
License #598372
WORK ORDER
NISSHO JOB # CLIENT P.O. #
Proposal IWO
COC Roadside City of Carlsbad
Project Name Client Name
(760) 434 2922 Paul Harrison
Client Phone # Authorized by (Pnnt)
paul harnson@carl5badca gov
email Authorized by (Sign) Date
Nissho Internal Only
- 1^ (Maintenance, Department)
<,
Gregg Fonseca
Project Manager (Pnnt)^*
Sales Rep Approval (Sign) MgmtApprovaL
DETAILED DESCRIPTION OF WORK TO BE PERFORMED , „ ^ ^
This proposal is for the installation of a irrigation system along Cannon Road just west of the railroad crossing and the
interstate 5 freeway The proposal includes installation of a DIG LEIT solar powered 4 station irrigation controller (1)
dark green powder coated gaurdshack backflow enclosure (1) weathermatic 8200cr master valve (3) weathermatic
8200cr irrigation control valves (1)1 Nelson quick coupler valves and (30) 12 rainbird spnnklers and (10) 5gpm rainbird
bubblers AH associated valve boxes concrete work (for the controller and backflow) and pipes and fittings are also
included in this proposal The area of installation will be checked via a dig alert to ensure no interruption of utilities and
the area will be checked post installation to ensure proper function All materials and labor are included to complete
the installation
. MATERIALS QTY PRICE TOTAL
Irngation Matenals 1 $6 437 04 $ 6,437 04
$
$
LABORS ^* ^ HRS RATE TOT^L
Foreman (trenching and pipe layout) 20 $ 33 OO $ 660 00
Laborer (trenching and pipe layout) 20 $ 33 00 $ 660 00
Irrigation Technician (controller concrete valves spnnklers testing) 12 $ 45 00 $ 540 00
$
1 GRANDTOTAL $ 8 297 04
THESE SIGNATURES BELOW CERTIFY THAT THE AREAS HAVE BEEN THOROUGHLY INSPECTED BY THE UNDERSIGNED
REPRESENTATIVE IT HAS BEEN DETERMINED THAT THE INSTALLATION IS IN ACCORDANCE WITH THE PLANS OR THE AGREED UPON
SPECIFICATIONS BY THE DEVELOPER/CLIENT AND NISSHO OF CALIFORNIA INC
Nissho of California
Representative
Client
Representative
Sean Lyon
Pnnt Sign Date
Pnnt Sign Date
NISSHO OF CALIFORNIA INC
1902 South Santa Fe Avenue Vista California 92083 Phone 760 727 9719 Fax 760 727 8706
License #598372
NISSHO JOI # CLIENT P.O. #
WORK ORDER Proposal LC 5 Planting
ity of Carlsbad Cannon Parkwa
Project Name
(760) 434 2922
Client Phone #
Kyle Lancaster(5)carlsbadca gov
City of Carlsbad
Client Name
Kyle Lancaster
Authorized by (Pnnt)
E Mail Authorized by (Sign Date
Nissho Internal Only
(Maintenance Department)
Gregg Fonseca
Project Manager (Pnnt)
12 29 13
Date
Sales Rep Approval (Sign) Mgmt Approval
DETAILED DESCRIPTION OF*WORK TO BE PERFORMED
Cannon Rd South side due West of Rail Road Tracks
Dig Alert Demolition of Existing Fences Trash and old plant removal Site Grading Instal new
Irrigation system Instal New Fence Instal New plant material MULCH site
NOTE If soil testing confirms the need for additional amendment a separate Nissho Proposal will be submitted to City
^-MATERIALS % QTY PRICE TOTAL
4 WEEKS PRIOR TO PLANTING PICTURES OF 24 BOX TREES NEED TO $
BE APPROVED BY ARCHITECT A LIST OF PLANT NAMES AND NURSERY $
ORIGIN LIST OF AMMENDMENTS FERTILIZERS AND SUPPLIERS NEED $
TO BE SUBMITTED TO CITY OF CARLSBAD and MULCH SAMPLE $
15 gal Phormium tenax Rubrum 13 $ 11500 $ 1 495 00
24 Box Launs nobilis Standard (Staked and Cinch Tied) 9 $ 265 00 $ 2 385 00
5 gal Hesperaloe parvifolia 14 $ 15 50 $ 217 00
5 gal Lantana montevidensis Radiation 30 $ 14 00 $ 420 00
5 gal Salvia leucantha 18 $ 15 00 $ 270 00
5 gal Lantana montevidensis New Gold 14 $ 21 00 $ 294 00
5 gal Muhlenberbia rigens 34 $ 17 50 $ 595 00
Carlsbad Stump Mulch (Cubic Yards) 20 $ 58 25 $ 1 165 00
tree stakes & cinch ties for trees 18 $ 11 50 $ 207 00
soil ammendment Fertilizer tabs Gypsum 1 $ 377 00 $ 377 00
LABOR, ~» f« " ~ HRS RATE TOTAL
Laborer 32 $ 23 00 $ 736 00
Foreman 16 $ 27 00 $ 432 00
$
1 GRAND TOTAL $ 8 593 00
THESE SIGNATURES BELOW CERTIFY THATTHE AREAS HAVE BEEN THOROUGHLY INSPECTED BY THE UNDERSIGNED
REPRESENTATIVE IT HAS BEEN DETERMINED THAT THE INSTALLATION IS IN ACCORDANCE WITH THE PLANS OR THE AGREED UPON
SPECIFICATIONS BY THE DEVELOPER/CLIENT AND NISSHO OF CALIFORNIA INC
Nissho of California
Representative
Client
Representative
Print Sign Date
Pnnt Sign Date
CALIFORNIA ALL-PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
State of Califomia
County of ^7W~^-^ O
On ^A^^ 17. 7.01^ before me, JO^-AJ Q.AoiM.f,joci . iQcVhUA PcMecl
'^(HoeiniBnnuiw'&ul title of lhe.Qfl]^)
personally appeared d^C-ilt'A f-rf^tjo ^oLjeAo^
who proved to me on the basis of satisfactory evidence to be the personj^^) whose name^O subscribed to
the within instrument and acknowledged to me that j^she/tl)^y executed dte same in {ui/her/t(t8ir authorized
capacity(i^), and that by I^er/tl^r signatur^on the instniment the person(|i;). or the entity upon behalf of
which the person^ acted, executed the instrument
I certify under PENALTY OF PERJURY under the laws ofthe State of Califomia that the foregotag paragraph
is true and correct.
WITNESS my hand andofficial seal
SlsnaUiieofluiaiy Pubiie
JOHN RAYMOND
Commission # 1969344
Notary Public - Califomia
San Oiego County ^
My Comm. Biplfw Mar 10.20161
(NouuySetd)
ADDITIONAL OPTIONAL INFORMATION
DESCRIPTION OF THE ATTACHED DOCUMENT
(Wl
(Titte or description orattBched documenl)
(mc «r docHpiton oTuuched documtm comfatue)!)
Number ofPages Document Date^^zA^.
(Additional infiinitttion)
CAPACITY CLAIMED BY THE SIGNER
• Individual (s)
• Corporate Officer
• Partners)
• Attomey-in-Fsct
• Trustee(s)
• Other
INSTRUCTIONS FOR COMPLETING THIS FORM
Any aehmvlt«^meiit eoa^tatd In Catlfenita mitsi coitfa/n vtrblas« *x«etfy ta
a/ftttn ahem in Ike naaiy teaton or a tepenot aebimritigneni fom mm bt
pr^ttfy <empltted anJ MaeheJ to tha doement. Tlu only omptfoi Is ^o
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verbU^e dots net require iht nouay u do semeikbtg ihai Is llltgatjbr a notaiy In
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» Sate and County infoimation mutt be tite Stale and Ceim^ wiMte the documou
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commitsiwi foiiowed by a comma and then your title (notaiy public).
• Print the nanie(s) of document sigiiei(s) who peisonally oppear at the lime of
notaiizalion.
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