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ORIGINAL
CITY OF SAN BERNARDINO REQUEST FOR COUNCIL ACTION
From: James Funk, Director
Subject: Resolution approving Final Map for
Tentative Tract Map No. 16795
located between Belmont and Ohio
Avenue, approximately 1200 feet
northwest of Palm Avenue.
Dept: Development Services
Date: December 5, 2005
File No.: TR No. 16795
MCC Date: January 9, 2006
Synopsis of Previous Council Action:
None.
Recommended motion:
Adopt resolution.
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Contact person: Lynn Parker, Sr. Civil Engineer
Phone:
Ex!. 5110
Supporting data attached: Staff Report, Reso, Agreement & Map
Ward: 5
FUNDING REQUIREMENTS:
Amount: None
Source: (Acet. No.)
(Acet. Description)
Finance:
Council Notes: d,o{)b~!),"
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Agenda Item No. --1 5
CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
STAFF REPORT
Subiect:
Resolution approving Final Map for Tentative Tract Map No. 16795 located between Belmont
and Ohio Avenue, approximately 1200 feet northwest of Palm Avenue.
Back2round:
On November 3,2004, the Planning Commission approved Tentative Tract No. 16795 for 54 lots
(Subdivision No. 04-09).
The developer, Belmont 54 Holdings, LLC, has posted the required bonds and insurance and has
executed the standard Subdivision Agreement to guarantee the construction within 24 months.
All conditions for map recordation have been satisfied.
Financial Impact:
None.
Recommendation:
Adopt resolution.
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12/19/054:01 PM
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RESOLUTION NO.
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RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY OF
SAN BERNARDINO APPROVING THE FINAL MAP FOR TRACT MAP NO. 16795,
LOCATED BETWEEN BELMONT AND OHIO AVENUES, WEST OF THE V ACA TED
CHESTNUT AVENUE IN THE RL, RESIDENTIAL LOW LAND USE DISTRICT,
ACCEPTING THE PUBLIC DEDICATIONS AS SET FORTH ON SAID MAP; AND
AUTHORIZING EXECUTION OF THE STANDARD FORM OF AGREEMENT FOR
THE IMPROVEMENTS IN SAID SUBDIVISION, WITH TIME FOR PERFORMANCE
SPECIFIED.
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY
OF SAN BERNARDINO AS FOLLOWS:
SECTION 1. The Mayor and Common Council find that proposed Tract Map No. 16795,
located between Belmont and Ohio Avenues, west of the vacated Chestnut Avenue in the RL,
Residential Low land use district, together with the provisions for their design and improvement,
is consistent with the General Plan of the City of San Bernardino.
SECTION 2. The Mayor of the City of San Bernardino is authorized on behalf of said
City to execute the standard form Subdivision Improvement Agreement with Belmont 54
Holdings, attached hereto as Exhibit A, for the improvements in said Tract Map as are required
by Title 19 of the San Bernardino Municipal Code and the California Subdivision Map Act. The
time for performance is as specified in the Agreement. Said improvements are specifically
described and shown on Drawings approved and on file in the office of Development Services of
the City of San Bernardino.
SECTION 3. The Final Map of said Tract Map is hereby approved and the City of San
Bernardino hereby accepts as public property all dedications within the subdivision as shown on
said Tract Map for streets, alleys (including access rights), drainage and other public easements.
As a condition precedent to approval of the Tract Map, the Subdivider shall first execute the
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RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE CITY OF
2 SAN BERNARDINO APPROVING THE FINAL MAP FOR TRACT MAP NO. 16795,
LOCATED BETWEEN BELMONT AND OHIO AVENUES, WEST OF THE VACATED
3 CHESTNUT AVENUE IN THE RL, RESIDENTIAL LOW LAND USE DISTRICT,
ACCEPTING THE PUBLIC DEDICATIONS AS SET FORTH ON SAID MAP; AND
4 AUTHORIZING EXECUTION OF THE STANDARD FORM OF AGREEMENT FOR
5 THE IMPROVEMENTS IN SAID SUBDIVISION, WITH TIME FOR PERFORMANCE
SPECIFIED.
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7 agreement referenced in Section 2 hereof for the improvements within said Tract Map limits.
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The City Clerk shall certify approval and acceptance of the Mayor and Common Council
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as set forth in this Resolution.
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SECTION 4. This Resolution is rescinded if the parties to the agreement fail to execute
12 it within sixty (60) days of the passage of this Resolution.
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RESOLUTION OF THE MAYOR AND COMMON COUNCIL OF THE
CITY OF SAN BERNARDINO APPROVING THE FINAL MAP FOR TRACT MAP NO.
16795, LOCATED BETWEEN BELMONT AND OHIO AVENUES, WEST OF THE
VACATED CHESTNUT AVENUE IN THE RL, RESIDENTIAL LOW LAND USE
DISTRICT, ACCEPTING THE PUBLIC DEDICATIONS AS SET FORTH ON SAID
MAP; AND AUTHORIZING EXECUTION OF THE STANDARD FORM OF
AGREEMENT FOR THE IMPROVEMENTS IN SAID SUBDIVISION, WITH TIME
FOR PERFORMANCE SPECIFIED.
I HEREBY CERTIFY that the foregoing resolution was duly adopted by the Mayor and
Common Council of the City of San Bernardino at a
meeting thereof, held
on the
day of
, 2006, by the following vote, to wit:
Council Members:
AYES
NAYS
ABSTAIN ABSENT
11 ESTRADA
12 LONGVILLE
13
MC GINNIS
14
DERRY
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16 KELLEY
17 JOHNSON
18 MC CAMMACK
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20 City Clerk
21 The foregoing resolution is hereby approved this day of ,2006.
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24 Approved as to
form and legal content:
25
JAMES F. PENMAN,
26 City Attorney
27 BY:~~
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Judith Valles, Mayor
City of San Bernardino
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AGREEMENT
(Subdivision Improvements)
THIS AGREEMENT is made and entered into as of tillS
lhl\ 0 f
, 2006, by and between the CITY OF SA:--.i BERNARDI0:0, a Municipal
Corporation, hereinafter referred to as "City," and Belmont 54 Holdings, LLC hereinafter
referred to as "Subdivider."
RECIT ALS
A. WHEREAS, Subdivider has presented to City for apprO\al a final subdivision
map (hereafter called "map") entitled Tract Map 16795; and,
B. WHEREAS, the map has been filed with the City for presentation to the City
Council (hereinafter called "Council") of the City for its approval, which map is hereby
referred to and incorporated herein; and,
C. WHEREAS, Subdivider has requested approval of the map prior to the
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construction and completion of improvements, including all streets, highways or public ways
and public utility facilities which are a part of, or appurtenant to. the subdivision (hereillJftcr
called "subdivision") designated in the map, all in accordance with, and as relluired by. the
Plans and Specifications for all or any of said improvements in, appurtenant to, or outside the
limits of subdivision, which Plans and Specifications are now on file in the Office of the City
Engineer of the City; and,
D. WHEREAS. Council has approved said map and accepted the dedications
therein offered, or some thereof, on condition that Subdivider first enter into and execute this
Agreement with the City; and,
E. WHEREAS, This Agreement is executed pursuant to the pro\'isions of the
Subdivision Map Act of the State of California and Title 19 San Bernardino Municipal Code
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NOW THEREFORE. for and in consideration of the approval of the map and of the
acceptance of the dedications. or some thereof, therein offered and in order to Ilbllle
satisfactory performance by Subdivider of Subdivider's obligations under said Subdi\ISl01l
Map Act and said Ordinance, the parties agree as follows:
I. Performance of Work. Subdivider will do and perfornl, or cause to be done
and performed, at Subdivider's own expense, in a good and workmanlike manner. and furnish
all required materials, all to the satisfaction of the City Engineer of City, the \\ork and
improvements within (and/or without) the subdivision to complete the imprO\'ements in
accordance with the Plans and Specifications on file as hereinbefore specified, or with any
changes required or ordered by said Engineer which, in his opinion, are necessary or required
to complete the work.
2. Work: Places and Grades to be Fixed bv Engineer. All of said work is tn be
done at the places, of the materials, in the manner, and at the grades, all as sho\\ 11 upon ,hc
Plans and Specifications therefor, heretofore approved by City Engineer and which arc no\\
on file in his office, and to the satisfaction of said City Engineer.
3. Work: Time for Commencement and Performance. City hereby fixes the limc
for the completion of said work to be within 24 months from the date hereof.
4. Time of Essence - Extension. Time is of the essence of this Agreement;
provided that, in the event good cause is shown therefor, the City Engineer may extend the
time for completion of the improvements hereunder. Any sLlch extension may be gral1kd
without notice to the Subdivider's surety, and extensions so granted shall not relieve Ihe
surety's liability on the bond to secure the faithful performance of this Agreement. The City
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Engineer shall be the sole and final judge as to whether or not good cause has been sho\\n to
entitle Subdivider to an extension.
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5. Repairs and Replacements. Subdivider shall replace. or haw replaced, or
repair. or have repaired, as the case may be, all pipes and monuments sho\\n on the nl.lp
which have been destroyed or damaged, and Subdivider shall replace. or ha\ e replaced.
repair, or have repaired, as the case may be, or pay to the owner the entire cost of replacement
or repairs, of any and all property damaged or destroyed by reason of any work done
hereunder, whether such property be owned by the United States, or any agency thereoL or
the State of California, or any agency or political subdivision thereof. or by the City. or b\
any public or private corporation, or by any person whomsoever, or by any combination elf
such owners. Any such repair or replacement shall be to the satisfaction, and subject to the
approval, of the City Engineer.
6. Utilitv Deposits - Statement. Subdivider shall file with the City Clerk. priur to
the commencement of any work to be perforn1ed within the area delineated on the map. a
written statement signed by Subdivider, and each public utility corporation in\ol\'ed, to the
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effect that Subdivider has made all deposits legally required by such public utility curporation
for the connection of any and all public utilities to be supplied by such public utilitv
corporation within the Subdivision.
7. Permits: Compliance with Law. Subdivider shall, at Subdivider's expense,
obtain all necessary permits and licenses for the construction of such improvements, gi ve all
necessary notices and pay all fees and taxes required by law. Subdivider shall comply with all
provisions of the Subdivision Map Act and Title 19 San Bernardino Municipal Code.
8. Superintendence bv Subdivider. Subdivider shall glH perselnal
superintendence to the work on said improvement, or have a competent foreman or
superintendent, satisfactory to the City Engineer on the work at all times during progress. with
authority to act for Subdivider.
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9. Inspection bv Citv. Subdi\'ider shall at all times maintain proper facilities and
provide safe access for inspection by City to all parts of the work and to the shops wherein the
work is in preparation.
10. Contract Securitv. Concurrently with the execution hereof. Subdi\ider shall
furnish to City improvement security as follows:
(a) An amount equal to at least one hundred percent (100%) of the total estimated
cost of the improvement and acts to be performed as security for the faitht'til
performance of this Agreement;
(b) An amount equal to at least fifty percent (50%) of the total estimated cost of
the improvements and acts to be performed as security lor the payment of all
persons performing labor and furnishing materials in connection with this
Agreement; and.
(c) An amount equal to at least twenty-five percent (25%) of the total estimated
cost of the impro\'ements and acts to be performed as security for the guarantee
and warranty of the work for a period of one (I) year following the completion
and acceptance thereof against any defective work or labor done, or defecll\e
materials furnished.
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As a part of the obligation guaranteed by the security and in addition to the
face amount of the security, there shall be included costs and reasonable
expenses and fees, including reasonable attorney's fees. incurred by City in
successfully enforcing the obligation secured. The type of security fUllllShcd
shall be in the form of bonds, deposits or letters of credit as pro\'ided in Title
19 San Bernardino Municipal Code, and the type shall be at the option of and
subject to the approval of the City Engineer and the City Attorney.
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II. Subdivider's Insurance. Subdivider shall not commence work under this
Agreement until Subdivider shall have obtained all insurance relluired under this paragraph.
and such insurance shall have been apprO\'ed by City Attorney as to form. amount and carrier.
nor shall Subdivider allow any contractor or subcontractor to commence work on his contrilct
or subcontract until all similar insurance required of the contractor or subcontractor shall ha\'e
been so obtained and approved. All requirements herein provided shall appear either in the
body of the insurance policies or as endorsements and shall specifically bind the insurJnce
camer.
(a) Worker's Compensation InsurancelEmployer's Liability Insurance.
Subdivider shall maintain. during the life of this Agreement. Worker's
Compensation Insurance and Employer's Liability Insurance tor all
Subdivider's employees employed at the site of impro\ emenl. and. in eel:i,' an\
work is sublet, Subdivider shall require any contractor or subcontra.:tor
similarly to provide Worker's Compensation Insurance and Employer's
Liability Insurance for all c,mtractor's or subcontractor's employees, unless
such employees are covered by the protection afforded by Subdivider. In cas.:
any class of employees engaged in work under this Agreement at the site of the
project is not protected under any Worker's Compensation Law, Subdivider
shall provide, and shall cause each contractor and subcontractor to pro\ide.
adequate insurance for the protection of employees not othef\\isc protected.
Subdivider shall indemnify City for any damage resulting to it from failure or
either Subdivider or any contractor or subcontractor to take out or maintain
such insurance.
(b) Public Liability and Property Damage Insurance. Subdivider shall take out and
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maintain, during the life of this Agreement. such public liability and propeny
damage insurance as shall insure City, its elective and appointi\e boards.
commissions, officers. ag~nts and employees, Subdl\ider and any contractor 01
subcontractor performing work covered by this Agreement from claims for
damages for personal injury, (as defined hereunder), including death, as \\'ell as
from claims for property damage or product liability which may arise from
Subdivider's or any contractor's or subcontractor's operations hereunder.
whether such operations be by Subdivider or any contractor or subcontractor.
or by anyone, including, without limitation, agents, employees or independent
contractors, directly or indirectly employed by either Sllbdivider or any
contractor or subcontractor, and the amounts of such insurance shall be as
follows:
(1) Public Liability, Insurance. In an amount not less than One Million
Dollars ($1,000,000.00) for injuries. including. but not limited to.
death. to anyone person. and, subject to the same limit for each person.
in an amount not less than One Million Dollars (SI.lJOO.OOU.IJUI 011
account of anyone occurrence; Product Liabi Iity Insurance coycrage
should be part of the Public Liability Insurance;
(2) Propertv Damage Insurance. In an amount not less than One Million
Dollars (5 I ,000,000.00) for damage to the property of each person on
account of anyone occurrence.
In the event that any of the aforesaid insurance policies provided for in this
Paragraph 11 insures any entity, person, board or commission other than thosc
mentioned in this paragraph, such policy shall contain a standard form of
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cross-liability endorsement, Insunng on such policy City, its electi\e "no
appointive boards, commissions, officers, agents and employees, Subdi\idcr
and any contractor or subcontractor perfom1ing work co\'ered b\ this
Agreement.
(3) Tail Coverage. Insurance co\erage, albeit for public liability or
property damage, shall be written, if possible, on an "occun'ence" fonl1
rather than a "claims made" policy. If the insurance policy is \\Tillcll
on a "claims made" policy. then additional co\-erage. entitled "lail
coverage" must be purchased to cover a period of one (I ) year from
completion of the project. All subcontractors must and shall comply
with the same insurance provisions as the contractor( s) and
subdivider(s).
(4) Personal Iniurv - Defined. As used herein, the tenn "personal Injury
shall be defined as a hurt or damage to one's person including, without
limitation, damage to health, cuts, bruises, broken limbs and,or bones,
or the like, disabilities or impairments, including aggra\'atiun of
existing InJunes, or invaSIOn of personal rights, including libel or
slander criminal conversation, maliciolls prosecution, false
imprisonment and mental su ffering.
12. Evidence of Insurance. Subdivider and contractor shall fumish CltV.
concurrently with the execution hereof, with satisfactory evidence of the insurance required.
and evidence that City is named and endorsed on the policy as an additional insured.
Subdivider and contractor shall also provide City with evidence that each carrier "ill be
required to give City at least ten (10) days prior written notice of the cancellation or reduction
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in coverage of any policy during tbe effective period of this Agreement
13. Hold Harmless/Indemnification. Subdivider(s)/Developer( s) heteby agree to
and shall protect, defend. indemnify and hold the City and its electi\'e and appointi\ e boards.
commissions, officers, agents. employees and servants free and barnlless from any and all
liability losses, damages, claims, liens, demands and cause of action of every kind and
character including, but not limited to, the amounts of judgments, penalties, interests, court
costs, allomey'sllegal fees, and all other expenses incurred by the City arising in favor of an)'
party, including claims, liens, debts, demands for lost wages or compensallon. pCrSlJlla[
injuries, including employees of the City, death or damages to property (including property of
the City) and without limitation by enUlr.:ration, all other claims or demands of e\ery
character occurring or in any way incident to, in connection with or arising directh or
indirectly, (including from the negligent performance by its officers. employees. agcnts) from
the terms of this Agreement. whether such operations,incidents arc caused b\ C011traCiOr.
Subdivider or any of contractor/Subdivider's subcontractors, contractors or by anyone 01'
more persons directly or indirectly employed by or acting as agent for contractor, Subdi \'ider.
or anyone of contractor or Subdivider's contractors or subcontractors. Subdividcr/Developer
shall investigate, handle, respond to, provide defense for and defend an)' such claims.
demand, or suit at the sole expense of the Subdivider/Developer even if the claim or claims
alleged are groundless, false or fraudulent Subdivider agrees to, and shall, defend City, its
appointive boards, commissions, officers, agents and employees from any suits or actions at
law or in equity for damages caused. or alleged to have been callsed. by reason of an) of the
aforesaid operations, provided as follows:
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(a) That City does not, and shall not. waive any rights against Subdivider which it
may have by reason of the aforesaid hold hannless agreement, because of the
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acceptance by City, or by deposit with City by Subdivider, of any of the
insurance policies described in Paragraph 11 hereof.
(b) That the aforesaid hold harmless agreement by Subdivider shall apply to all
damages and claims for damages of every kind suffered, or alleged to have
been suffered, by reason of any of the aforesaid operations referred to in this
paragraph, regardless of whether or not City has prepared, supplied or
approved of Plans and/or Specifications for the subdivision, or regardless of
whether or not such insurance policies shall have been detennined to be
applicable to any of such damages or claims for damages.
This provision is not intended to create any cause of action in favor of any third party against
Subdivider/Developer or the City or to enlarge in any way the Subdivider's/Developer's
liability but is intended solely to provide for indemnification of the City from liability for
damage or injuries to third persons or property arising from Subdivider/Developer's
performance hereunder.
14. Title to Impro\'ements. Title to, and ownership of, all improvements
constructcd hereunder by Subdivider shall vest absolutely in City, upon completion and
acceptance of such improvements by City.
15. Repair or Reconstruction of Defective Work. If, within a period of one year
after final acceptance of the work performed under this Agreement, any structure or part of
any structure furnished andlor installed or constructed, or caused to be installed or constructed
by Subdivider, or any of the work done under this Agreement, fails to fulfill any of the
requirements of this Agreement or the Specifications referred to herein, Subdivider shall.
without delay and without any cost to City, repair or replace or reconstruct any defective or
otherwise unsatisfactory part or parts of the work or structure. Should Subdivider fail to act
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promptly or in accordance with this requirement, or should the exigencies of the situation JS
detemlined by the City in the exercise of its sole discretion require repair. replacement or
reconstmction before the Subdivider can be notified. City may. at its option. make the
necessary repairs or replacements or perfornl the necessary work, and Subdivider shall pay to
the City the actual cost of such repairs plus fifteen percent (15%).
16. Subdivider Not Agent of City. Neither Subdivider nor any of Subdi \'ider's
agents or contractors are, or shall be, considered to be agents of City in connection \\'ith the
performance of Subdivider's obligations under this Agreement.
17. Cost of Engineering and Inspection. Subdivider shall pay to City the costs of
all permit fees for all engineering inspections and other seJ"\ices connected with the City in
regard to the subdivision. Said fees shall be paid prior to commencing any construction.
18. Notice of Breach and Default. If Subdi\ider refuses or 1~lils to Oht"ll1
prosecution of the work, or any severable part thereof, with such diligence as ,,111 insure Its
completion within the time specified, or any e:xtensions thereof, or fails to obtain completion
of said work within such time. or if the Subdivider should be adjudged a bankrupt, or
Subdivider should make a general assignment for the benefit of Subdivider's creditors. or if a
receiver should be appointed in the event of Subdivider's insolvency, orjf Subdivider. or any
of Subdivider's contractors, subcontractors, agents or employees, should violate any of the
provisions of this Agreement, City Engineer or City Council may serve written notice upon
Subdivider and subdivider's surety of breach of this Agreement, or of any portion thereof. and
default of Subdivider.
19. Breach of Agreement: Performance bv Surety or Citv. In the e\ent of any such
notice, Subdivider's surety shall have the duty to take over and complete the work and the
improvement herein specified: provided, however, that it the surety. within five days after the
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serving upon of such notice of breach, does not give City written notice of its intention to take
over the performance of the contract, and does not commence performance thereof within ti, 0
days after notice to City of such election. City may take over the work and prosecllte the same
to completion, by contract or by any other method City may deem ad\'isable, for tho aCCOtilll
and at the expense of Subdivider, and Subdivider's surety shall be liable to City for any
excess cost or damages occasioned City thereby; and, in such event, City. without liability for
so doing, may take possession of, and utilize in completing the work, such matenals.
appliances, plant and other property belonging to Subdivider as may be on the site ofth.: \\011
and necessary therefor.
20. Notices. All notices herein required shall be in writing, and deliven:d in
person or sent by registered mail, postage prepaid.
(a) Notices required to be given to City shall be addressed as follows:
City Administrator
City Hall
300 North "D" Street
San Bernardino, California 92418
(b) Notices required to be given to Subdivider shall be addressed as follows:
Belmont-54 Holdings, LLC
434 NQrth Second Avenue, Upland, CA 91786
(c) Notices required to be given to surety of Subdivider shall be addressed as
follows:
Strong Surety Insurance Services
4850 Arlington Avenue. Suite B, Riverside, CA 92504
Provided that any party or the surety may change such address by notice in writing to the
"
other party, and, thereafter, notices shall be addressed and transmitted to the new address.
21. Successors Bound. This Agreement shall be binding upon and inure to the
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,
benefit of each of the parties and their respective legal representatives. successors. heirs and
aSSigns,
IN WITNESS WHEREOF, the parties hereto have executed this Agreement of the da,
and year first above written.
ATTEST:
CITY OF SAN BERNARDINO
By:
City Clerk
Judith Valles, Mayor
City of San Bernardino
Approved as to roml
and legal content:
SUBDIVIDER
JAMES F. PENMAN,
City Attorney,
By: Selmon t 54 Holdings, LLC
By:
~~.
oM
By: Fe iz rdo ROblefJ~------
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-....~,"
INSTRucnor-<s
If the Subdivider is a corporation, the Agreement must be executed in the coq)orate
name and signed by the President or a Vice.President and the Secretary or Assistallt
Secretary, and the corporate seal affixed. If the Subdivider is a partnership, it musl be signed
by all partners. If the subdivider is an individual doing business under a fictitiouS name. It
must be signed by all persons having an interest in the business, and the fictitious name must
On this S U<- day of hrc: "",b.<. v _, 2005, before me, the undersigned, a
Notary Public in and for said Cou~ and State] personally appeared
T~/.l-c<.J,-,~-":'b/rS or-
personally know to me (Gf Ilre. cd to Ul~ UII tile basis of Sllt;sf"dvl y e, id.::,,~~) to be the
President, llftti- personally k.tlO\\lltiJ
roe (or proven ..to- me 01. the bllsis of satisfactory p\'irlencel--l.o--he,Afte"
of the corporation that executed the within instrument, alld
know to me to be the person' who executed the within instrument on behalf of the corporation
therein named, and acknowledged to me that such corporation executed the same. pursuant to
its by-laws, or a resolution of its Board of Directors.
WITNESS my hand and official seal.
be signed also. The Agreement must be notarized.
ST ATE OF CALIFORNIA )
'2 ) ss,
COUNTY OF~G, ~u<",,-cL ,"~ )
/i
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13
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I----:::~----
ICEIIlIIl.lUI.ClMT
JG ~.tlllIoM7'2 J
NaIary PubIc . c-... f
---~~~~
--
(This area for official seal.)
...~_.. ..~. '-
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^mcrican Contractors Indemnity Company ~ 'e
c!/ Y'2:i
'-
Subdivision Improvement Bond
EXECUTED IN DUPLICATE
[Jond No 23365,,-,_
1)1"i..:'1l11Ull1 ~ ~ I ,2JU I)()
KNOW ALL MEN BY THESE PRESENTS
n:ll.
BEL\tONT q 1I0Ll)I~c;S. 1.1 C
____' a__ Prilh':lp,d,
,\Ild ,\IllI2I'lL',m C\)l1lr,ll.:hllS Illdcl11lll!} C~\ll1p,1l1Y, ;ll\)rp~)fdIIUl1llr!:-'JllIICd ,1IH.i C\I_sllllg lllllkr llll' 1,1\\'-, (11"111..: SI,lI-.: (II
C,ll1forlutl <lnd ,1lllhorllCJ to transact surelY hU~ll1c~S III The Start' of Call1um],!. ,I'" Surety, ,11'(' held <lnd firmj:. hd\llltl
lllll() ___.._______~_'LIr~G~~~~BL R!'J A F-J?I ~,'(-~ ..~~~'~~_!l~_(~~1 r(~l~l.l~t~_~____
;IS Obllge-:. III lilt' SUlll 1,,1
_ 01\1. \HUION Ft\r IIL>;[)R[D SIHYI\\_'L1.fl(ll:SAM) A~m2'iI.~J~~_~~__ (S_I~'''2-,,'IIQ_'Ji(
I. to! Ilk'
pd)'IllL'llt whereof. \\'dl ,lI1d truly 10 be nude. Stl1d Pl1l1lJp,I! ;ml! Suret; bInd !JK'lllst:hl...'s. !llL'lI heirs, adI11l11IS1r~\I~lI-'-,.
SlICCCSSurs ,111...1 ~L"SIg.ns, .I0inlly: and SL'vL'Llll)-'. IIl'1lIly by tl1L''ie prl''iCll[~
1 HI: ('UNDITION OF THIS UBLI(;,\ TION IS SUClt TII,\T \\l1c"o",. ,l1e I'lIllc',!,,,I,,,,
DITI\lIlll( ,
:?n05
enlered intD an Agrcemcnt \\llh the Obligee \\ herein [he Prlllclpal agreed [0 cOlllpkll' ~ill.'
~ roll~)\\lllg llllp1'()\'Cments
STRlTT J~,1[>RO\T:V1F:\TS. STOT\r--l URAl\' 1~\iIPH()\'L:v1l::--Jl~. S..\:'\ITi\RY SEWER
1\11'((()\T,II,N IS, /\ND I...\I\DS(AI'I~,G ..\"1) IRRI(,,\T10c. HHZ TRM T 1I,~"j
;lS Illore fully ~(:{ forth III S:lh.! r\~:~rl'enll'nL \\ Inch l.) ,1lldcl1ed hl..'rct..J ,llhllllade ,I P:ll'l hl...'rel1( h)- reference:
\iO\\.'. THEREFORe if the Pnnclpal Shill! well ilnd truly pl'rrpl'lll Jllll rullill all uf the (0\'I...'I1;1111s. lerl11" alld
CUl1dllH1l1S of Ille SJid Agreement. thell this obligJl101l shilll bc !lull :Hld \'0111 ulherwlse 10 ITlll.lJIl In full force ,ll:t!
cllcct. ProVldccL how~\'lT I) Th,H Ihe cOllscnlurSurcly shilll bl.: required hn .:lny C\{CIlSH)1l (d' IlIne lu complele s;lld
Jmpruvell1cllt~: 2) Th.:11 no rrghl or :lClll)l1 ~I1JJl dccrllC hereunder (0 ur for lhe belle!ll ~)f :lllY pcr:-il111. linll e'l
(~lrJ)()r;l1j()ll othcr thall tile obligL'c nillllcd herelll
SIgned. scaled and cbted
D,:cclllbcr ~8
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lJEl,IOI\T ,.I ItOLIJI:-JGS, Lll
('11111,"1)'11" ,-". ,r'
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By' & /- " y., /
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American Contractors Indemnity Company
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ScS^^ C. MONTEON
AtWrnCY-IIl-I:,ld
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-
,
CALIFORNIA ALL.PURPOSE ACKNOWLEDGMENT
'P5;<'~..('"~'.C<-~:..~~<:Z""-Y-6~5:i:!::.""~--c<'~,C<'..c<'C<'-C<'-C<'C<'-<:<'5:L.~O:-'i:S:_.,(;;!:~_~"ct''''--;<'0~7:<'Q:-Q:'Q~:Q<".c<'.6('.(';<''''''").1
,~ q
p State of California } q
;) ss,"
'.' RIVERSIDE 0
i'~ County of q
(! IJ,
~ i'
~ On 1J.IJ&J[Jl)' R. CISNEROS ~
~, V , before me. "
(' Date Name and Tille 01 OI1,cel (e 9 Jane Doe NOlary Put-lie j ')
'~ I;
~ personally appeared SUSAN C. MONTE;ON 8:
P. NamelS) of S'gner:s, t'
d X
c ']'> personally known to me ,
B c:: proved to me on the basis of satisfactory ~
~ evidence ~
~,~ to be the person(M" whose name}81 is/jlf<!( ~
subscribed to the within instrument and ,
~ .' . R. CISNEROS acknowledged to me thatbe1she/~ executed ~
.D - . COMM. #1488731 the same in .l:lis/her/lJ:le'rr authorized IJ,
~ " NOTARY PUBLIC. CALIFORNIA capacity(.ies1: and that by .b<siher/J.l:leif q
8 t ~ RIVERSIDE COUNTY ti
,< ~. M Comm, Ex Ires June 7, 2008 signatureWon the instrument the person!~ or,
1-' the entity upon behalf of which the person% ~
~ acted, executed the instrument. ~
8" ~
1-1 WITNESS my hand and official seal. ,
.~ ,/';) < IJ,
~ ~,C~p~ IJ,
,'.J Place Notary Seal Above . S.gn,ll<Jr~ of NOlal)' PubliC ~
~ ~
,~ OPT/ONAL q
~ q
~ Though f.'1e indforma'dlJon be/OWt Is ndo" required by iawd, it m,ay prove V8f'U8lJ/: to personShrelYdlng on the document g
t" an cau prevent Irau u en! removal an rea tacnment 0 thiS larm to anat er acumen!. ti
~ ~
N Description of Attached Document (J,
,~ Title or Type of Document: q
~ ~
<"'I Document Date: Number of Pages: .~
g ~
~ Slgner(s) Other Than Named Above: ~
~ ~
1 q
~ Capacity(ies) Claimed by Signer ~
I-i Signer's Name: ,0
~ ^
~ ',Individual i(J,"
l Top 01 IhufTlb here
h :J Corporate Officer - Title(s): ~
~ 0 Partner - C' Limited =.J General ~
8 lJ Attorney In Fact ~
~ [J Trustee (J,
1'1 [J Guardian or Conservator ~
8 [J Other: ti
~ ' ~
f! Signer Is Representing: I~
d ~
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@ 1993 Nall:!nal Nold')' ASSOClallon' g350 De SOloA~e PO 80.2402' O'a's..orth. ell, 9131J-2402' ....wndl,on~lnOI<lrvO'9
Reo'~ef Call Toll-Flee 1-800-876-6827
P'M No 5907
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American Contractors Indemnity Company
-
Sl'BDI\lSION I\IPROYE\IENTS
LABOR AND \IATERIAI. BOND
EXECUED rei DlPLlCA1E
233656
BO"IJ "0.
PRE~lll'~1 INCLlIDL".D Ii','
I'LRFORM\NCE BOND
h::\O\\' :\1.1 \lFS HI THFSL l'RFSI:!\T:'l
Ih." '" BELMONT 54 HOLDINGS LLC ,," !'<'", '!'"
d;ld /\-l1--:;-~:-I-~...:~m (~;1lI~,i;~~~~fli~c~i,~'l;i'>;c'~~~~:l2i;11~" ,I L'\lIV01;lllf)1l (11':,..';1ll11Cd ,ll1d t!(lll:;c 11\:"111'
UIl,lel ,11\.1 11\ \nluL' l1f tilL' I.!I\" t>1 1I1L' SI;\[t: ill C~lIltOl 111,1 .111;.! tilll\' IIcellsl'd t(\ L'!ll1dllLl ,I ~L'I1L'I~d "1:IClV hLI'-IIl":"" In !Ill' SLlk (\1 (~iliil)lill,;
SUI ','1\. ,Ii L' t;L'ld ~\Ild fllml\' 1'\\III;d unl\l the ~JI~QE__~~~J?_~_F3~A8.9l~.9--,-.6J~J.l!~~~~Q[QQ.r_?tlon_
." (l! !'!,T 'n tile' pcn..! 'nn, "I SE'yEt'LHJiNQRi::CLE1GJ:UY_QNEnTHQ,L"l\lJQuI\N~HQlJilil',::_,_:_=-:c. - :" ',:_'':
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1'>1 \\!Jk'l1 )',1:111'.'111, \n:11 ;lIhlllul\ 10 he n:;:,k. \\;': bind \l\:I~L'I,..:". nUl 1l1'11\.I'\i.:lutUl" ~ll1d "Ul"':l.:"Sf!t". jlllllt!) ~IIlJ "\.'\<"'[,,11') [111\11-- h: li~,''',
PI":"L'I,I-
THE CO~lJI1IUN UF IIll ORII(;..\TI()~ ts seclt TH \1
\\'lh'IC;I", the :lb(\\,~\l.lIlh-,d 1)1111..11,,11. 1l,1" Cilkf,'d Illlp :In d;-:lL'l'lIll'IIl \\ IJILh 1\ 1I1<!(k ,I P:1I1 ,11 [hI'- hUlld, WI[ll [Ill"
CITY_ 9f_';;~N_8E~_~~RP~N~O---"~_~~l.:l..Q~~IJ~g~.2r9tl?n SLIlc e,1 Ctid'U!lll,1. d" Obligee. JUI Ill\.: lk'J:,..'ll,:ku pul'!',
1IIIpW'.i.'llllill" illlhL' 'ollhdl\ 1'-1(111 Ilklltltlcd ,\"..sJ[e.~J JrlJP!_Qv.~rnent$, SJQnJ1Dr~I[1"I.r!lPJ.9.vem~nl.s. .S.,ar:lI!9[Y-S~W~f ,l,mprQ.YS?Olents
an_9_ L3':.?2C.~E:.~9._~.:'.9 .~~r~9atlo.0J~_~~r~_~~ 16?J?_ ~ .1" I L'qUllL'd h:, llll.' Ci\I\LTllIlll'lll ClH.k dl ('..1:1\'1,.>"
\\IlL'l'l',IS. 1I1hkl till: I,! Ilh llt "did ,1~IL'(111CI1I. PIIIIl':p"II" ll:qUIIUJ b-:!tllc (lll":III1.~ UpOI1 tilL: 111.'11l'11]I.1I1(,' pI' IIlL' \\'\11 k. III rile d ~l)t>LI ,lild
--Ut(ILIL',\[ p:I)111L'.11 bOli..! \\ltllll1..: G_IT'(i)F ;;At:'.J_BJ;_RN~RP!NQ_ III "t'LUIl.: IIIL' ll;1111;.
Iu ll!iI,): 1"::'L'I,'llo.;l: IS li1.(,k III Tille I:) lCOI:,I1:,'IlCII1~ \\Ilh S,',Jlpn _l\)K~) ()11\ill-1 III 1)1\-1"\(11]\ (l~ !Ile en'lI CllllL: of lhl: SI~lle ll! C.ililurill,:
...... '\,>11. II~LI\'f'J'L'. ".ild 1I':I1(;i1..1 ,lIid JIll" \llld__'I"I~11L"! ,h '-,~Ih'(), .1:": lidd II: 11,1) h'llllhll~ill\) 1 Ill' .Y1T'y'_9.f_ SA~l3:~RN.A,RDI!~O _
/~, rvlunlclp_al C~~poratl,?n _ __ ________ .111<.] .111 i...OlllldCI\II", ~lIbi.:(ll]ll<li.l()1 ", bh(lIi.:I" 11l~llen.dlllCI1 ;lJld ul ll.... I 1)1,,'1"\1:"
..'ll1pl\l\..'d II11he PI:IIll1111;111...:L';)1 [11;: ;durC:--dIU .1:,..'I":l'I\lL'111 dll,: Iderled tOl111hL' :lr,II,~..,lld l(,,1e \11('1\11 f'1()u:dlll\.' 11l111l;1[::n;i111111i1,h..:d U: !,1:1,,,
lhcl":llll ,11 ;111:-' kind, \'r lor .11l1,lllll!:; uu,' undcl [1l,'l.'ilL'lllplll)lll":il[ 111"1I1;1I1lL' ,\Cl With IL'LI'Co.;ll11 :--till: \\1.'1" ()I LdllJl.lh,11 "diU "Lliel', \1111 1".1'
till \~:111L' III dli i111\\lunt Ilul l'_\(('..:dlll~ IIlL' ]len,1I "U1ll hL'lL'llldbu\L' sCllullh, ;\lld ,d..,l III LI'-,C "U:lIS hlUtl~lll UP<)!l [hIS [1(lIlll, \\111 ;JdY. In ,Ilidlll,':'
II) IhL." pCIj;i1 ~1I1l11hL'n:()I. L"(hh ;1:1U IL';ISOIl.lhh: ~',\pL"lhC" ::11...1 Ice:--. IIlLludll1); lC!\(1I1dblc ,llloIIlCY" 1\'1.:"_ 111Ull: ,'d by __~L~,(_Q~
$A.N_B.~~NJ:\RQl~.Q_ _____ _ _________ __ _~__::1 "\'Lu_s,tlllh l:IlI(oJlll1~ "lIlb IIbll);,III()Il, 1(1 he av..lIded ;1I1d II\cd h llll' ,nul
011 It! III 11l' (;I\l.:d ;(\ ;,.'o'-,ts :lnd 1(1 be 11Kludl'd 11111l..: !Ud,::cI11eI111h":lcin I'endclcd
II I" hereby C\j1IL""s:\..trpuL\lnl ;1I1d ;\~IL'ed lli;ll (hi" hill,! .\11;111 i1llll-~' \0 [he bcneflt \It C111~ ;lIld ;111 PL'I"OIl", L"Olllp;lI1lL:" dllt! ,'(\IVI\'.,I,llJi:'
CIHillL:,IIO 11iL' LLIIlll" umkl TI[ic i~ t,OllllllClll'lil:; wllh SCL"lIOi1 3()~~) ur P,IlI..\ uf !)l\I"I()Il.' \>1 lllc el\'d Cod\.'. ~<.1;(" to ~I\C Ij~l:l "I ,1\.ill'l! ["
Ihl'111 (lllh":ll "'''!;;11.'' 1:1 ;l1l.'- "U;l blt)uglil Up\ll] (hl~ h(llHi
ShUllld the L"\)l1d;II()il "I [111.\ L'IHld bc full)' pel 1lli ll\cd, Ihcl11hl'l \lhll&illl(l!l ,,11;111 hCL"lllllC Ill;!1 ,11lL! \(IJd. \llllcr\\l"L' I[ \hall bL' ~l!1tI;Cl1id:1
:11 full tOIL'C ilnd cft":d
Th,,' "Ull'ly h':lChy "llpuLle's ;l!1d ,\~Jc(:" thdllll1 <.:1];II1;;'l:. L'\[::Il~I(l1l of 11111('. ;dler,ILH1l1 PI ;lddlllOI1 lu the tt:llll_" III ";11...1 ,1~r<,::clllClll ,11 lh
"1,,-,uJI,'<JlJ(]ll" ,1(:,'Pll1i';IIl\ll1g Ill,' ';11110: ,h;dlI11 ;\11) ll1..nl:cr dlkcl 1['1 obllg;llIl1m un Ihis bond. dnd \( duc" helcby w;uvc Ilul,<.:e l)! ilny 'LIi.-11
...:h~111~l', C\!L'il"l,lI1. ,llkid{I()l1 111 ,ld,illll'll
111 \',lllless \I l1eleo,l!. 1111\ ilhtlllllKIlIII,l'- hL'L'I1 duly L'\L'cuIL'd b~ tIlL' PlllKlp,il dill! "lIrel\, ;ihi!',C ildlllnl on .12/28/05
?OO~._ ,_, .
PRti\ClPAL ;~~,MOc~T ~H~LDLINGS:_LLC_
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(;?/;;~~~~d. ,__
SURETY Ameril':lIl CuUfntclurs Indcrnllity Comp.lll~
, ^ /~L.lb..", ~ --"\/u",C""",~.L_
p_ _ _~_______m__ _ _ _ ~ .~.
Susan C Monteon t\lhlrn':)':li-F~kl
"",,,,..:..-
. \_.'.Il'"''
"-
.............
CALIFORNIA ALL.PURPOSE ACKNOWLEDGMENT
-:--Q:::SZ::<:---C<'4"'<'.c.:-C<'.c<'..C<'<:<,,C<'-C<'c<'-<X'K:<'-C<'.c<,C<'..."Y'.c<'-C<""'--:<'~Si"'~....5:5:.~,c<'.c<'<:<'~::!:i!:~~~.!:;<~~.r<'.c<'.c<'.c<'<'''_">
/ (..,
:3 State of California } ~
, ss, 'I
: County of RIVERSIDE ~
~ ~
~ '
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:; On ,;;..I.,>'is~~;> ,before me. R. C~::;;o~~'~O'O"w,g ""Do, "o"c, Po' <0 1 ~
8 personally appeared SL'SAN C. MONT~ON ~
~ Name(s, of-S;~~ f
P [']I personally known to me q
~ ~
:. =:J proved to me on the basis of satisfactory ^
~ evidence q
/ ~
Q., R CISNEROS to be the person~ whose namejsf is/~ ~
~ u; -" COMM. #1488731 subscribed to the within instrument and q
2, . NOTARY PUBLIC, CALIFORNIA - acknowledged to me that,be1she/th....' executed '2
,~ . RIVERSIDE COUNTY ~y~;
(. .,,' M Comm. E, Ites June 7, 2008 the same in .l:>is/her/lJ>eli' authOrized q
I:> capaclty~ and that by ~her/1J:leff q
~ signature!:>yon the instrument the person~ or ,I;,
~ the entity upon behalf of which the person~ ~
> acted, executed the instrument, I;,
~1 ~
~ WITNESS my hand and official seal. ,I;,
~ r:e'.L~- ~
~ - (:
,~I ">
,~ Place Nolary Seal Abc~E' S,gnalute of Nolary P"bhc q
X ~
~ ~
i' S,
j OPT/ONAL ,
~'1 Though the information below is not required by law. It may prove valuable to persons relying on the document _~
B and could prevent fraudulent removal and reattachment of thiS form to another document X
~ g
~ Description of Attached Document ~
~ Title or Type of Document: g
~ ~
j Document Date: Number of Pages: q
8 ~
" Signer(s) Other Than Named Above: 0
~ ~
,~ Capacity(ies) Claimed by Signer "',~
~1 Signer's Name' :~
f,: Individual . g,",
(_ ,- Too at thumb here ~;
~ LJ Corporate Officer - Title(s): ~
(" Partner - C Limited 0 General ;~
~ ~
~ u Attorney in Fact ~,o
("j 0 Trustee :">
~ !J Guardian or Conservator ~
~ [] Other: ~
~,~ ~
'1 Signer Is Representing: q
~ ~
<~D...---Z;:Z~~~~"CA'(..;..,.:(.;-<.:<,^..,(.:..,.;<':'<"''V<...-~<<~~~-C;Z;-<:Z~~~~~0C"--C::Z:';:;;~:;,,=,;<::~-q:'C<~z--cz,...._,;.(.:~.;.,;~~
iC 1999 Nallenal NOlary ASSOCIJI<Ofl. 93S0 De Solo A.e PO 6".2402' C~als"'m'ttJ. CA 91313.2402' ",,",,",nallonaln:)\a,, org
(>,O~ No 5907
Reo.de, Call To".F,ee '_800_876.1;827
,.,......~~.-- ',,' ..- -..- -..
American Contractors Indemnity COl11pany~
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EXECUTED I~ DUPLICATE
UUN[) ",0 . 23365,6
/,f([~lll'M JNCLl'DE[) TiC'-"
PERFOR}1ANCE BOW
"-'
l\IAINTE:\IANCE BOND
I(\OW .\LL ~IE" 131' TIIESE PRESENTS, TI"'I we,
rm\lONT '4 HlJLDI;o;CS. LLC
______~_________________ _________._.._____ _ _"'___~___, ______...____ (hL'I'L'll~<lf!(..'J
"':Jllctl PrlllClp~lI). :J:-i PllJh.:lpal. dill! t-\!\.lr:RIC',-\!,\ C{):\TR,\CT()R~ INDi\lNITY ('O\'IP.'\NY,;J corpnratlUll. tlr1;:lJll/;,,'d
:1I1d (,\;'lsll1l~ umkr the I:\\\'~ i..1lthL' Slatl' orC:llllurtlJJ ~ll1d ;!Ull1ll\'l/cd In Ir,lllS,lct a general :-iLlr...."lv bUSlllCSS lJltl1C SI~lle <)!"
~~I~qJ3.7\[A ______._ (herclllafter c;tlled Surcly), <1:-. Surcl::>', ;11'0: held and tinnly hi..HlIltlUlllO
C'I,!"Y ()~.?:\N AERN~.~.QIN~~\ r\ll1n~.!~~~~~~___
(hCl"t'\ll:1f'ler CJllcd Obl1gce). lil the Sllm of TJ-lRfT 11\~'2::DrU:~D NI~!~~~LS,~~!!_ FIVE l-lLNDRED 0'\,\1) 1\0 ] {_)~_._
_ ~.~.....:...:-=~ .. ... - . . - _ -_ "'u: :..:-=--=----=-_~~_~~ - . . - ~_ -__:. :__-_.:....:~ -. . " ________ DOLLt\ RS ! S .]~_~~~ ~~~)
Ll\\'(ullllOlll')' or 1110: lI11I~l'd SUlc.':-. u!' /\JlH:nL:l. 10 Ill" p,-lld lu !h~ :-i:l1d Oblrgee. or II', SLlCCl'~:-i~ll ~ nr :IS:-iI!:,Jh. 10 the pa~, IllC\ll
n!' wl1lcl1 SLlIll \'v~!l :llld truly to ilL" mack, \A'e do !lllHJ l)ur~clvcs. OUl' hell's. C\eclltors, tldministrators, SUcccss0rs ,uld aSSI~!"'"
IOllllly ~lIld severally, linn!y by Ihese presents
\VHERL.\S, the Princlp:\1 i..'1Hered into ,1 C(llltr,lct with the ~:lld Obligee, d~l!l'd _!2~'~~~lJ~CI '. :i.)~"-____.~__________
I'ur S T R r 1~~~~.1!~{()V~~~:.~TS, .~TUR ~~_,~~~~rR_~L~.~r~~~~~_'_~'~~:Ll~.~~~~.~I~~~~~~11' 11:~~'L- ~ 1 F r~~.:..~~~~_ ___
LA\D5CAPII'(; AND IRRI(;ATIO" fOR TRACT 1(;",15
"'-.,.,.
<lnd.
\VI-IEREr\S. lhe Obl1g~c requires tlwt thIS bond b:: ('.\ccukd UI1 0r b..:forc the 1111,11 completlull tlnd acccJ1l~lllLC l)( s,l;d
contract and
\VHERE^S said i..'onll'<lc! \\',lS completed <llld ~\ccqllC'd lln the
t1:\\
llr
~ow. TlIEREFORF. TltE CON DITlON OF TlttS OIJLlCi.\ TION IS suel!. th"llrlhe Plme,!",1 shall remedy
\\lllwut cost tll the OblJgec, <lilY ddc'ClS '.\111(:11 1ll.lY dncll'p during (l period of_____----.-2:~NE _~.~:,\R~__ _.___..
fr\Hll [he d.ltc of Cl'lllplctl01l ,llld <lCccplJncc of the \Vlll'h performed under lhe cOlllr:lcL GlllSecl by defectlv~ 01 11l(Crilll
lll;l1ena]s or \\drkmanship, the]} fillS obligilliull shJJl be VOId: other\\ise it sh(llll"lc and ITlll~lill III fllll force ilnd dleCl
SIC,NED, SEALED A:\D 0,\ TED TillS __....m__~:.~"'-_ DA l' OF
I)[C[MBER
:(lO~
BELMONT 54 IWLDINCS. LLC
- ~:;?~~ L:mCIP"1
l3yL2'~""'" ::::,;-?:-.,-. ?
. -
A~lERteAN CONTRACTORS INDEM"ITY COM I'A,", "
X
fly L1.l-\...l.<'"~.,- Q. ~\A_~'~~~~_____
Stl~,-In C :\,:[OIlICOI1, ,~\!lOrnCY-]ll-Fac[
'-
IH,,//,,:I.(..."J
-
-
'-
CALIFORNIA ALL.PURPOSE ACKNOWLEDGMENT
~~.:Q~.c<'-..c<-<:<,-<..--":-.c<''<;<'J:::<'~-<:;<'"c<~~~~~~~..c<..c<'.c<j;'-:''''-c<'..,.-..r-c<'.c<'<"".(''('C<',.o^o~~:G::~~~1
~, State of California } ~
~ RIVERSIDE ss, S
," County of 'i
(0 ~
~ 9
~ On ia-I J.'6/0 5 , before me. R. CISNEROS ,~
~ Dale Name and T':le 01 C~,:e' Ie 9 :ane Doe. Notary PLJbr.c .J q
~1 g
P personally appeared SUSAN C. MO~TE:O~ "
<~ Name(SI ot S,gner s; ~
N ~ personally known to me g
~ CJ proved to me on the basis of satisfactory ~
-") evidence t!
(~ ~
~ g
~1 to be the person~ whose nameW is/;>fe' g
,'~ subscribed to the within instrument and g
~ .. R CISNEROS acknowledged to me that ~she/\J:le)' executed 3
~ - COMM. #1488731 the same In .t>iS/her/.tl:lefr authorized ~
C!, a;' NOTARY PUBLI,C. CALIFORNIA capacity(;~ and that by J:li6iher/1J>eif "I;
(: _ RIVERSIDE COUNTY K:I~',:)
,~ .' M Comm Ex Ires June 7. 2008 signature~on the instrument the person~ or g
P the entity upon behalf of which the person~ g
~ acted, executed the instrument. ~
10' -\
~ WITNESS my hand and official seal. ~
8 ~C g
~, " , \....~ 0 ^ J9..<:.i . g
,~ Pla,:e Notary Seal Above S'gnalure of NOlary PlIol,c ,q
~ g
P OPTIONAL g
~ Though the mformation below IS not required by law, It may prove vo/uabfe to persons relying on the document ~
,~ and could prevent fraudulent removal and reattachment of this form to another document ~
~ Description of Attached Document ~
~ Title or Type of Document: X
~ ~
~ ~
10 Document Dale: Number of Pages: .,
~ "
~ a
.0 Signer(s) Other Than Named Above: !\
~ ~
,~ Capacity(ies) Claimed by Signer g
~ Signers Name ~
<": =: IndiVidual . ~
1 Top or thumb here (>i
, ~ [! Corporate Officer - Title(s): ~
~ [j Partner - L; Limited C General ~
8 ,~Attorney in F act g~',
C1 ~ Trustee
{~ !
'\1 [J Guardian or Conservator ~
,~ _ Other ~
N ~
~ g
~ Signer Is Representing: ~
~""'>~<_=-<:;~<;<"-====-Q;~~"C;Ye<..v..D.,,,,--=<<'U..cycy<<=cy~,,""TI;"'-,===~~<.;<,.v..,,'''''<''-<Y~
Cl1999 Nat,onal NQla"l A~~OC,allon. 9350 ~ Solo Ave PO 60' 2~02' C~als""or1h. CA 91JI~.2~02' ww.... raMna1nol<lrfO'9
Reo,(je' Call TOII-F,ee \.800876.6827
P,'O<jNo.5907
.....
A{~t~~r;.a,:::'.!,I:':1~:::..~::~any ~@
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS;
"- -- -- - -,
. - - - --
_ ____..n_
That_~~e~i~h Contr~ct()rs'l~dem~ity Company ofthe State of California, a California corporation, does
Michael D. Stong, Shawn Blume or Susan C. Monteon of Riverside, Ca'~fornia_,
;.,
its true and lawful Attomey(s)-in-Fact, with full authority to execute on its behalf bonds, undertakings, 'iecognizances and other contracts
~~ of indemnity)md,"}itings obligatory in the nature thereof, issued in the course of its business and to pindtlie Company thereby, in an 'l,
--Amount' not to excee-d $ **********2,OOO,OOO.OO~***"***~ _. This .P9~ef:o{d't}grf[~~ shall ~:xpiI"e-_!Vi~o~f_fUrt_~er action on fyfan:;-b;':!"
18,2007.: _ ';-
-- -- ..-
This Power of Attorney is, granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by
the Board of DirectorSofAMERlCAN CONTRACTORS INDEMNITY COMPANY at a meeting duly called and hellL<>n,~e 6'" day",Qf:':" :~
December, 1990. __ --- _ - -- ---'- 'i;'<>~I!~ :';;~1~
_ :~!:,,:.i "Ii'
"RESOL VED that the Chief Executive Officer, President or any Vice Preside'nt, Executive ~:ice_ Pre$i/J~-'#,"Sei:rejary or JiirJSllInt Secretary, shall have the
power and authority
I. To appoint Attorney(s)-in-Facl and 10 authorize them to execute on behalf of the Company,t1I,,d'attach iheseal of the Company -iher~io,':: -~"
bonds and undertakings, contracts pi int/em!1tly and. other writings obligatory iri-the nature t~~reof and,
... - -- .....----- ---- - ...-..- -- -- -.- ',- -' ,,-
2. To~erri4i1el:a'-~n:f:'tin{e';:~l1ny SUchl{ggr'!ey-iB-FaC) and revoke the authority given.
~ -- -
-.-- --- -
---- --
.. . - --.-- ------ -- -
-.. - ... -.--- --- --
RESOLVED FURTHER'- that the signatures of such officers and the seal of the. Company may be affIXed to any such PO~~1';ofAttbrneji~r certifi#i:~ 'I- i
relating thereto by facsimile, and any such Power of Attorney or certificate bearing suchfacsimilesigllatures or facsimilf seal shall b~VI1li<l.and bindinEfi:;; ~ -
upon:~~e.,<;o~~y a'lff any suchpowerso:executedand certified by facsimile signatures andfacsimile seal shall be valid aild binding upon the Company
In-qti/uiiire{>i!itlifespect 10 any bond or undertaking to which it is attached"
- ---
_IN WlrNESS\vHEREOF, American Contractors Indemnity Company has caused its seat to be affixed hereto and executed by its Chief
Executive Officer on the IS'" day of December, 2003.
AMERICAN C NTRACTORS INDEMNITY COMPANY
By:
STATE OF CALifORNIA. 9
'" Y;\ltJoNTY Q~~f~At'GrLEs' 9
"\~, 6j, tl\is 15th da);- of De~~mtier 2003, before me, Deborah Reese, a notary public, personally appeared Rob~flE",T%>J11as;,J;:hief Ex5"~<< I"':i
Officer of American Contractors Indemnity Company, to. me personally knowrt: t~" ~e: t~~ ,i~;~ividual a.na'~fflC~{ d~~~ hereUi,,:-~ihm ~ -~
acknowle~ged,!l'at he executed the foregoing instrument and affixed the seal O!S~d~orr~#i!joQ;!pereto b':aijjh1lriij..Jfhl5 ~ffice. --~-="* '~~
____".,.."..- ".__c_,_'-y,_ __~,,~~~ -_' ." ._"_0 ", .'1.' ',-' "
.~r~5:0d~;::al. ~_!~~E~i'
SIgnature ~f1ll9lll,ry:,~" ':',' ~ MyComm. ExpteoMor 18, 2007
MY Commission expires March 18.2007
;,;",1'."'.1'>'
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"~-
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--~
1, Jeannie J. Kim, Corporate Secretary of American c;ontractors, 1ndemni~~iiJ ~by ce.la1~'{~f Attolilaii
resolution adopted bytbe I3?ard of Difectors of $~!IlC~mp~n~ ~ set ford$[~ti'f~,= ll\d correct'iTaIl'sCH)fu111ereof and tilaf neither
the said Pow~r of Atl<ll1jeY:J]oqhe(eso1ution hav.beenrevoked and they ai.now in full force and effect.
IN WITNESS HEREOF','I -have hereunto set my hand this J.'31h dayp(
I
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American Contractors Indemnity Company ~c
c' J) 'iJ
........
Subdivision Improvement Bond
EXECVTED I~ DUPLICATE
BI.))1d \:()
233657
Pn:::IllI\llll S 30(J (1\1
1(,,0\\ ,\LL MEN BY ItlESF PRESENTS
ll1~11.
BU_~1()~T ~4 HOL[)lN(IS:..l..!_~____________._____________,:1S PI!ncil"\~:I.
:l1ld AlllcnL',lIl CLllltr~C1l1rs Illdcll1l\J[). CUll1pan~,,',;1 c()]"por~ltHm ur!;~lIlJ/:cd ~lIld \:..'\JI.,tl:l,!; 1I1ldL'r lhc I;I\\'-; of lhe SUlc uj'
CalJfoml,1 and authorized 10 triJllSJcl ~L1n.::ty bU~Jl1e~s in lhl' Stale oj' (;dil-ornl~l. as Surely. ,-m: hl'Jd <lnd firtn'> bOl:nd
Ullto ~___~__l'LTY OF )f~~B.J{0:r'~.!~.I~C). '~_~~~.~..~.P~~~.i!~11~~_.____.___ _,b ObhgL'C. ill the "'U!ll ,1/
_~~!rTI'.I-:N l~)l!~~ND A~~C!_~)~-'-::n-_=-:""::.~~_:_.~_~----=--=---=-':'-=--:_:._~_-_:":"":""-=---==-=-=---- (S ~;':J!.0u_~!!!_____). fur lhe
p.l>lllc'llL \\h..:-reur, \vcll illld truly Lo be Ill:lde. ....~lId PlllKi[1<l1 <lI~d Sur'~'ty bllld tilcl1lsehL''i. lhl:n heirs, ;ldlllijlISlr,\\(l[s.
SlICCeSSi.H~ Jnd assigns. lom!ly ;llld st'\'Crally. firmly by' Ihc.'lc presents
THE C01\DJTION OF THIS OBLIGATION IS SUC!I TI L'\ T Whele:", the I'nllClpal on
f>FlI'MIJFR i
~(lO~ cntcr..:t! Inlo
<In Agreelllent \\Ith the Obligee \\herelll thL' Principal agrl'cd to complch.:
!I...
.11,-
"--' kdl,)\\ l11g 1mprC)\Tlllenl--
~IO;-.,Uj\lLNT'\T1UN I\)R T1(.\( 1 :(./'):'
.IS llliJre fully set fonh III s;lld Agrcem':.'ll1. \\hlCh J"i dt!achcd hereto and lll;ldc :1 P;lrl hClt'll( by rci"clellLc:
~o\V. THEREFORE. If lilt:: PrJIlClp:l! sh;lIl \\'(:'11 <tnd truly perform :llld rlllli,1 :111 GI" the Cl)\'('llallts. le['ms ;\l1d
cuntlllJtlllS or thL' said .'\grcl.'lllcIlL thell lhi.... Ubltg<.IIIUll shall bl.': null <llld \'oh1 olhen\ ISL' 10 n:J1lalll III flJI J'urcL' ~111l1
effect. Pn:wided. ho\\ C\'I"T ]) ThaI the CI.)llst:llt of Surety sh,111 he I"l"qUJrl'd for .lIlY c\tcnsit)Jl of Illlle to LomplclL:: ....<lld
IlllprO\'CllleJlls: ~) That no right or ~1L'llon shall ,ICcrUC hereunder 10 or rur the bellefit ur <lilY 11crson. finll U1
...:orp\)ratioll other than the obligee n.\1l1cd herein.
SIgned. st'Jled and d:ttcd
Ot:..:t:Il~bcr J~
200S
-----
Pl11lClP,11
BI:I.~tONT '4 HOLDINGS, ll.C
.-:./::~:,::/ /~
;;- ;{:7>i%~~rq~ _
Amcrican Contractor"S Indcmnity Company
,~ f-,..\J.l.<l.- '-. (~ /'U.'--()y~t:=:::..
th "/
SUSAN C. MONTEON
;',lturnI,,'Y-IIl-F,k'l
-
"-
"'-
'.......'
CALIFORNIA ALL.PURPOSE ACKNOWLEDGMENT
.:;~<;r6~0~<:<'-C<'<::<'<:<'~~-:<'..c<'<Y~.Q:'~<:s:Y....:5';<:.~,c('<:<c<'-C<'-C:<'~e<'"............~.-...;'..c.:"..c<'.c<'..c<'..c<'.Q:'~q~<<~~
<l~ \
,~ State of Calrfornia } ~
( ~
~ County of RIVERSIDE ss, ~
, 0
p "-
;: ~
.~ On j,)..ld'(/C25 ,beforeme, R. CISNEROS ~
\ Dale Name and T,lIe 01 OH,:er I,e 9 Jane Doe, Notary PUOhc'-j ,;
<" N ">
~ personally appeared Sl'SAN c. MONT!,:O _ __~ 'J,
~ Name(s;otS'g'1e,rs; r.
~~ -')
I;; Cl\ personally known to me ~
~ c::: proved to me on the basis of satisfactory 1
/', -\
~ evidence ~
> t1
? to be the person{M" whose nameM is/,af<'!" ~
~ subscribed to the within instrument and l
h .. R CISNEROS kid d t th t".... hi''''"'' t d '
r ~ COMM. #1488731 ac nowe ge 0 me a ...."s e~J execu e .~
P a: NOTARY PUBLIC, CALIFORNIA the same In .t>i-S/herl.tl>efr authorized !l,
; . . M co%~E~~~;e;~~n~T{ 200B capacity(ieS). and that by tlisiher/1Reif l
~ signature~on the instrument the person~ or '\
~ the entity upon behalf of which the person% ~
Q acted, executed the instrument. -\
~ q
~ -:)TNESS my hand and official seal. ~
~i /' ,,'. X
;~ -~/ C~ ~
t~ Place NotarvSealAbove ~ .... ~Pl)bhC ,~
> ~
f' OPTIONAL !l,
P ~
~ Though the Informallon below IS not required by law, It may prove valuable to persons relying on the document g
r'-i and could prevent fraudulent removal and reattachment of thiS form 10 another document t;
~ X
~ Description of Attached Document ~
~ Title or Type of Document: ~,'\
~ :'S
~ Document Date: Number of Pages: ~
~ ~
~ .~
~ Signer(s) Other Than Named Above: ~
8 ~
~,' Capacity(ies) Claimed by Signer ~"~
< Signer's Name: ~'S
;1 - Indr'vr'dual ~
" cc T I h h '~'
.. OpOlumoere
9 [J Corporate Officer - Title(s): ~
-:.01 L.J Partner - C Limited [J General ~
,'"
11 lJ Atlorney in Fact q
~ cJ Trustee ~
('-I LJ Guardian or Conservator ~
~ _OO~ ~
d ~
~ Signer Is Representing: ~
~:.:.c.v~-::-._".:,-_:"~~'U.~~J,",,,<..;.-;..~""?'~~zz..<..:..:.:(.:.(..:Q...:'uv~Z-~~<<---z-~~.cz.zz:~~;;:z..'(..;<..:,<;,,;'(,,(......~:,.;..;'(.,:.<.,~~---;c:;z:~.(.,..(,,;'(,..,'-..'U'~
tl '999 NiihOna: NOla,...,..~ssoc'al'on' 9351: De SOlO Ave PO Bo. 2402. C~alswo"h CA 91313-2402. wwwnal,onalnOla"'fo'g
P'od No 5907
Reolae' Ca:ITolI-Free 1-80087668,'7
........
~"'@S
Am~rican ContractorsIn~l:mnity Company ,'" ':,
9841' '\ir;;"rtBf~\i., 9'" Floor Los Angeles, California 90045
POWER OF ATTORNEY
~ ="=-
- -----.
-=."= =-~ ------
-~~~~ ~--~
- ----~,= =~~
,_~ ",._~=--,,; ~3
--'" ~=-~=;,,~:~,. ih~
KNOW ALL I\1EN BY THESE PRESENTS:
_ m _
That Amehcao Contractots Indemnity Company of the State of Cali fomi a, a California corporation, does hereby appoint,
Michael D. Stong, Shawn Blume or Susan C. Montean of Riversid~, Californi~
i-!
its true and lawfuTAJt~mey(s).in-Fact, with full authority to-execlite-on its behalf bonds; undertakings, recognizances and other co~tracts
of indemnity and witings obligatory in the nature thereof, issued in the course of its business and to, bind,~he COmpany thereby;!n an
. Amount not to exceed $ ....***..*2,OOO,OOO.OO~~*.:__~~..:.c:. This P~~eLo[:--A-q5'rfiey shall e:wjt~::wiibo~r.f~f!IJ,,-er action'~~' March;
18, 2007. .~ c.,~:~,,~ '. .. ,,' .... "
This Power of Attorney is'granted and is signed.rid seale'd'blfacs'imile under and by the authority of the following Resolution adopted by
the Board of Directoisof AMERICAN CONTRACTORS INDEMNITY COMPANY at a meetin~_duly call".~:ans h~1~nc~e 6" daY,,;~'11
December, 1990., '" ..' " ~~ , ".. j.'" ",'5>'~l.t" ~i;Jliii
"RESOL VED that the Chief Executive Officer, President or ~n.r President. Executive ViJ:_e..-!1r~~jdent, Secretary or AisistiJntSecretarf, shall have the
power and au/horUy . - - "
~:.
'!I"
'"
J. To appoint Attorney(s).in-Fact and to authorize rhem to execute on behalf of the. Company, and attach -f~e,~~a/ of the Company~Fierffq.<
bonds and un~:!'t~ki~gs, contl"Qc~~,,-~ "lJ!e!JI'i~,-_anr{9Iher wrjtin~! Q;~/ig~tdry in. the nature lhe~eof and, - -~.
2. To':;~v~~-'atanYli;;'e;_any such:Att~';';~;:in./ft44 <ifut revoke the au'thority given
...
. --_r '__
- -- --- ,- =~=- -
RESOL VED FURTHER, lhalthe signatures of such officers and the seal of the Company may be affIXed to any suchPo~ero!Attl)rl'!~'i;:~r cer/ifiitiJe.-1i- g i
relatmg thereto by facsimile, and any suchP~wer_of Altorney or cerlificattbearing suchfacslmile-signatures or facsimile f~al_;~h",{he,,-YQ/j'4;and b;nJr;~ ~ ~
upon the CompSW;: qg{J any such POWeF: so__executeii and certifi~iby facsrmile signatures andfacsimile s.eal shall be valid ahd binding "upon the Company
in the IUlure_lVltft...~rffft~1 to any bond or un,de~tC!&n&;~o which it is attached:"
--- -
" tN Wt'NESSWHEREOF, American Contractors Indemnity Company has caused its seal to be affixed hereto and executed by its Chief
-- Executive Officer on the 15'" day of December, 2003.
. --- -
AMERICAN C NTRACTORS INDEMNITY COMPANY.~
""'"
,I ", '~i
:1,\ /1'1
~':"~~"
By:
'i ,:i :/k, ,~'
STATE OF CAPE9RNIb- f:~
. . COUNTY 01' LQSAI'IGELES
s
s
;~i:?~m (]
~
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- --- - ---. ---
'3ond NO:.~J $.l;i51.
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ACORD..
CERTIFICATE OF LIABILITY INSURANCE
DAT[ ""U'D~,l'(Vl;
i
~D\Jci~ (714)245-2777 FAX (714)245-2788
Assistance Insurance Agency, Inc.
I 400 N. Tustin Avenue Ste 470
~ Santa Ana, CA 92705
! ;~ CFR -En-t-erp..::r ses. Inc--:---
I Behont S4 Holdings. lL(
I 434 ~o. Second Ave
, Upland, (A 91736
I
11/19/100,
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA TE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
AL fER THE COVERAGE AFFORDED BY THE POLICIES BELOW
i INSURERS AFFORDING COVERAGE
....~...Qt.... Quanta Insurance
1~,~s'.;F.~ile Quanta Ins-urance
L",,,~O:E~::
I NSt;~cq D
I '!."\.JrlE'I~--~---~--
i NAle".
COVERAGES _
r -~ME ~OLIC1E5 0'" II'IISi.;RANCE LS:IOD SHOW '"iAVE ar:E.'~ :5SJEl.i TO 7,..,E: 1r-.5u~Eu NAMc.D ,.lBCrV( ~OR T'-tE P(:'lIC'I' "Ert:Ov iNDICt. '~T:; NQ,:;'7HS"; A.ml....C
ANY REOL:IREMErJT. TERM OR COND'TIQ".! OF A~Y C:JIHRACT OR OTHER 'JOr;UMENT WITM RESPECT TO ""1"'::'; "hiS CERTIFiCATE MA'{ BE :$S:;::O OR
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I OESCRlP1IQfIrIor OPf:RA"ONS IlOCAflO"S I IIE>i:CL.ES "CXC~uSJO"5 AODEO BY (NllOP:SEr.Ill;NT I S~C1"'" PROVtSIO,",S
~ertltlcate holder is named as addltlonal insured with respects to;
~ocation: Tract 16795 in San Bernardino, CA
,
l~~~:,~!aY cl~~se in effect.
CERTIFICATE HOLDER
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CANCELLATION
SHOU~OANY OF ~Io4E ABOVE DESCllT8EO POLICIES liE CANCelLED BEfOR.E 'ME
City of San Bernardino
300 North D. Street
San Bernardino, CA 92418
E.l(P:R.ilTIOH DATE THEREO~, !"~ ,$SVI:":C; I"'SUIlEA WlllEN[)fAVOR TO MAil
_!~ DAVS WR.IT'!"[N ,"OTIC[ TO T'iE CER~!F'Clll'E HOLDE" N,I,MW TO THE lfF':'
BUT fAILURE TO MAl~ SUCH ,"OTICI: SHlllllMI"OSE NOOBU(lATION OR. L'AQIL!TY
or< #II"Y ,(INo lifO'" THE I'IOSJ R.. ors AGEJ;TS OR REPR ~l\jT."TI\I.S
ACORD 25 {2001/08)
AUTHORL.H.OREPRESI::..TATI'J/.
(r~i9_R,,~ ,__,__,.' ""U CO
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@ACORDCORPORATlON 1988
'~-,~
, - J
** FOR OFFICE USE ONLY - NOT A PUBLIC DOCUMENT **
Meeting Date (Date A:Ged): ~ Item #
Vote: Ayes () Nays
Change to motion to amend original documents 0
RESOLUTION AGENDA ITEM TRACKING FORM
\ ( Resolution# Ao~b ~ ~
Absent ~ ...../
Abstain
Companion Resolutions
Null/Void After: days /
Resolution # On Attachments: 0
Note on Resolution of attachment stored separately: 0
PUBLISH 0 POST 0 RECORD W/COUNTY 0
\1' \D ~ Dlo
Date Sent to Mayor: .
Date of Mayor's Signature:' Jj ')? 0 Jo
Date ofClerk/CDC Signature: \ ~ ,} (Vh
By:
Reso. Log Updated: C
Seal Impressed: ~./
Reso. # on Staff Report if
Date Memo/Letter Sent for Signature:
I" Reminder Letter Sent:
Date Returned:
2nd Reminder Letter Sent:
Not Returned: 0
Request for Council Action & Staff Report Attached:
Updated Prior Resolutions (Other Than Below):
Updated CITY Personnel Folders (6413, 6429, 6433,10584,10585,12634):
Updated CDC Personnel Folders (5557):
Updated Traffic Folders (3985, 8234, 655, 92-389):
ye/
NOr By__
NO-r By_
No By
No / By=
NO~y_
Yes
Yes
Yes
Yes
Copies Distributed to:
Animal Control 0 EDA 0 Information Services 0
City Administrator ~ Facilities 0 Parks & Recreation 0
City Attorney Finance 0 Police Department 0
Code Compliance ~v Fire Department 0 Public Services 0
Development Services Human Resources 0 Water Department 0
Others:
Notes:
/
Ready to File: .-J Date: 11(~Jt7~
Revised 12/18/03
CITY OF SAN BERNARDINO
Interoffice Memorandum
CITY CLERK'S OFFICE
Records and Information Management (RIM) Program
DATE:
January 13, 2006
TO:
Lynn Parker, Senior Civil Engineer
Development Services Department
FROM:
Eileen Gomez, Senior Secretary
RE:
Transmitting Documents for Signature - Resolution No. 2006-5
At the Mayor and Common Council meeting of January 9, 2005, the City of San Bernardino
adopted Resolution No. 2006-5 - Resolution approving the final map for Tract Map No. 16795,
located between Belmont and Ohio Avenues, west of the vacated Chestnut Avenue in the RL,
Residential Low Land Use District, accepting the public dedications as set forth on said map;
and authorizing execution of the standard form of agreement for the improvements in said
subdivision. with time for performance specified.
Attached is a copy of Resolution No. 2006-5 and three (3) fully executed original agreements.
We have retained a duplicate original agreement for our records.
If you have any questions, please do not hesitate to contact me at ext. 3206. Thank you.
Eileen Gomez
Senior Secretary
I hereby acknowledge receipt of the above mentioned documents,
Signed: Cj:{/2;.O !~ /
0' /17//00(:;
/ I
~
Date:
Please sign and return