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OFFICIAL NOTICE TO CONTRACTORS
NOTICE IS HEREBY GIVEN that electronic bids will be received up to 11:00 a.m., Monday, July
15, 2024, through the online bidding service of QuestCDN.com, www.OuestCDN.com, for
manhole rehabilitation, including replacing castings, installing chimney seals, grouting manhole
leaks, and appurtenant work. Bids will be opened and publicly read in Room 310 of City Hall,
215 Church Avenue, Oshkosh, Wisconsin, and through a Zoom virtual meeting.
CITY CONTRACT 24-11 — SANITARY MANHOLE REHABILITATION /
INFLOW/INFILTRATION REDUCTION PROGRAM
Replace approx. 100 sanitary and storm manhole frames and covers
Install approx. 95 external manhole chimney seals
Approx. 150 vert. ft. of sanitary and storm manhole repair/installation
Approx. 80 gal. of chemical grout
Approx. 100 vert. ft. of cementitious liner
Approx. 1,500 sq. yds. of concrete pavement
Approx. 400 sq. yds. of asphalt pavement
It is the Bidder's sole responsibility to ensure the Bid is received by QuestCDN.com prior to the
deadline set forth in this notice. No bids will be accepted after the deadline.
All bids must follow the bidding instructions, including providing all attachments as required,
on QuestCDN.com.
Contractors must be qualified to submit a bid for this Project. This shall be done on forms
furnished by the City of Oshkosh Department of Public Works, and must be filled out in proper
manner and then submitted to the Department of Public Works for consideration by the Director
of Public Works and the City Manager and filed not later than Thursday, July 4, 2024.
Contractors will not be allowed to bid on this City Contract if complete answers to any
Department of Public Works' questions or any missing documentation has not been received
by the Department of Public Works by Wednesday, July 10, 2024. The City Manager's decision
as to qualifications will be final. Contractors that are prequalified with the City of Oshkosh
Department of Public Works for the construction year 2024 for the class of work and the
Total Contract Amount specified in the Proposal do not need to prequalify again for this
Project.
Complete digital Project Bidding Documents (including a copy of the current edition of the
Standard Specifications for City of Oshkosh, Wisconsin) will be available at www.questcdn.com
on Tuesday, June 25, 2024. Download the digital plan documents for a non-refundable fee of
$42 (Forty Two Dollars) by inputting Quest Project No. 9184991 on the website's Project
Search page. Please contact QuestCDN.com at (952) 233-1632 or info@questcdn.com for
assistance in free membership registration, downloading, and working with this digital
Project information.
Plans and Specifications may be reviewed at the office of the City Engineer, Room 301 of City
Hall, beginning Tuesday, June 25, 2024. These documents are also available for inspection in
the office of the City Clerk, Room 104, 215 Church Avenue, Oshkosh, Wisconsin. In addition,
additional copies of the current edition of the Standard Specifications for the City of Oshkosh,
Wisconsin will be available for purchase. The cost of the current edition of the Standard
Specifications for the City of Oshkosh, Wisconsin will be $25 (Twenty Five Dollars) and will be
available at the City Engineer's office.
Sealed Bids must be accompanied by a Bid Bond payable to the City of Oshkosh on the form
provided by the City of Oshkosh in an amount of not less than five percent (5%) of the total
amount of the Bid as a guarantee that if the Bid is accepted, Bidder will execute and file proper
Contract and Bond within ten (10) days after the award of the Contract. The Bid Bond can be
presented in pdf format. If the successful bidder executes the Contract and files the necessary
bonds within the allowed time, then the Bid Bond shall be released. If the successful bidder fails
to execute the Contract and file the Contract Bond within the allowed time, then the Bid Bond
shall be forfeited to the CITY as liquidated damages.
No bids will be withdrawn for a period of sixty (60) days after the scheduled time of opening
bids.
The CITY reserves the right to reject any and all bids and to waive any informalities.
MARK A. ROHLOFF
City Manager
PUBLISHED: June 21 and 28, 2024
RECENED
CITY OF OSHKOSH
Contract Number Contract 24-11 Sanitary Manhole Rehabilitation / Inflow/Infiltration DEPT OF PUBLIC WORKS
Reduction Prooram OSHKOSH, WISCONSIN
Date Bond Executed (Date of Contract or Later) July 15, 2024
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
Vinton Construction Company
1322 33rd Street
Two Rivers, WI 54241
SURETY(IES) (Legal Name(s) and Business Address(es))
Travelers Casualty and Surety Company of America
One Tower Square
Hartford, CT 06183
OWNER (Legal Name and Business Address)
CITY OF OSHKOSH
215 Church Avenue
PO Box 1130
Oshkosh, Wisconsin 54903-1130
OBLIGATION
Type of Organization
— Individual _ Partnership
X Corporation
State of Incorporation
Wisconsin
Penal Sum of Bond
Five Percent of the Amount Bid (5%)
The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors,
and assigns to the Owner for the amount of the penal sum identified above if the Owner accepts the bid of this
Contractor within the time specified u1 the Bid documents or within such time period as may be agreed upon
between the Owner and the Contractor, and the Contractor shall fail to execute the Contract within five (5) business
days of written notice to the Contractor and Surety of Owner's intent to make a claim upon this Bond.
The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in
wluch the Owner may accept the Bid.
If the Contractor either enters into a contract with Owner in accordance with the terms of the Bid and gives such
bond(s) that may be specified in the Bidding documents for the faithful performance of the Contract and for the
prompt payment of labor, materials, and supplies furnished for the purpose thereof, or pays to the Owner the
difference between the amount specified in the Bid and such larger amount for which the Owner may in good faith
contract with another party to perform the work covered in such Bid, then the Surety and the Contractor shall have
no obligation under this Bond.
Page I of 2
Notice to the Contractor or Surety shall be deemed to have been given: (i) upon delivery to an officer or person
entitled to such notice, if hand delivered; or (ii) two (2) business days following deposit in the United States mail,
postage prepaid; (iii) upon delivery by a commercial carrier that will certify the date and time of delivery; or (iv)
upon transmission if by facsimile, e-mail, or other form of electronic transmission. Notices shall be provided to the
Owner, Surety, and/or Contractor at their address as specified on this Bond or to a facsimile, e-mail or other
electronic address that has been provided in writing to the other party to be used for tlus purpose.
The laws of the State of Wisconsin shall govern the interpretation and construction of this Bond. Winnebago
County shall be the venue for all disputes arising under this Bond. Any provision in this Bond that may conflict
with statutory or other legal requirement shall be deemed deleted herefrom and provisions conforming to the
statutory or other legal requirement shall be deemed incorporated herein.
``,INN/t III fit I",
w
Vinton Construction Company �.�`C�;r' `••; LC., Travelers Casualty and Surely Company of America �° ...
Name of Principal/Contractor V Opp C RAT ��`,O f3�Tame of Surety
SEAL
7 , 'r
Title MICHAEL J . dgKES / PREhI ,,,+��'� Title Kathryn A. Weidner, Attorney -in -Fact
Page 2 of 2
Travelers Casualty and Surety Company of America
TRAVELERS � Travelers Casualty and Surety Company
St. Paul Fire and Marine Insurance Company
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That Travelers Casualty and Surety Company of America, Travelers Casualty and Surety Company, and St.
Paul Fire and Marine Insurance Company are corporations duly organized under the laws of the State of Connecticut (herein collectively called the
"Companies"), and that the Companies do hereby make, constitute and appoint Kathryn A. Weidner of MADISON
Wisconsin , their true and lawful Attorney -in -Fact to sign, execute, seal and acknowledge any and all bonds, recognizances,
conditional undertakings and other writings obligatory in the nature thereof on behalf of the Companies in their business of guaranteeing the
fidelity of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted In any
actions or proceedings allowed by law.
IN WITNESS WHEREOF, the Companies have caused this instrument to be signed, and their corporate seals to be hereto affixed, this 17th day of January,
2019.
�w►`q�F\ 4Pg,P�Tr Apce`' �lgt*
j\j/ty1/8.,jjyf0 2 HARTrORD, �CiYJM�
Will. Ps UM
8
State of Connecticut
City of Hartford ss.
By:
Robert L. Rane , eniorVice President
On this the 17th day of January, 2019, before me personally appeared Robert L. Raney, who acknowledged himself to be the Senior Vice President
of Travelers Casualty and Surety Company of America, Travelers Casualty and Surety Company, and St. Paul Fire and Marine Insurance Company, and
that he, as such, being authorized so to do, executed the foregoing instrument for the purposes therein contained by signing on behalf of said
Companies by himself as a duly authorized officer.
1101.
r�ttiac.Loy�y,
IN WITNESS WHEREOF, I hereunto set m hand and official seal, c'
uoraev
v �fj <
My Commission expires the 30th day of June, 2021 a �1&- a (J
pupil() Anna P. Nowik, Notary Public
This Power of Attorney is granted under and by the authority of the following resolutions adopted by the Boards of Directors of Travelers Casualty and
Surety Company of America, Travelers Casualty and Surety Company, and St, Paul Fire and Marine Insurance Company, which resolutions are now in full
force and effect, reading as follows:
RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President, any Vice President, any
Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary may appoint Attorneys -In -Fact and
Agents to act for and on behalf of the Company and may give such appointee such authority as his or her certificate of authority may prescribe to sign
with the Company's name and seal with the Company's seal bonds, recognizances, contracts of indemnity, and other writings obligatory in the nature of a
bond, recognizance, or conditional undertaking, and any of said officers or the Board of Directors at any time may remove any such appointee and revoke
the power given him or her; and it is
FURTHER RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President or any Vice
President may delegate all or any part of the foregoing authority to one or more officers or employees of this Company, provided that each such
delegation Is In writing and a copy thereof is filed in the office of the Secretary; and it Is
FURTHER RESOLVED, that any bond, recognizance, contract of Indemnity, or writing obligatory In the nature of a bond, recognizance, or conditional
undertaking shall be valid and binding upon the Company when (a) signed by the President, any Vice Chairman, any Executive Vice. President, any
Senior Vice President or any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any
Assistant Secretary and duly attested and sealed with the Company's seal by a Secretary or Assistant Secretary; or (b) duly executed (under seal, if
required) by one or more Attorneys -In -Fact and Agents pursuant to the power prescribed in his or her certificate or their certificates of authority or by one
or more Company officers pursuant to a written delegation of authority; and it is
FURTHER RESOLVED, that the signature of each of the following officers: President, any Executive Vice President, any Senior Vice President, any Vice
President, any Assistant Vice President, any Secretary, any Assistant Secretary, and the seal of the Company may be affixed by facsimile to any Power of
Attorney or to any certificate relating thereto appointing Resident Vice Presidents, Resident Assistant Secretaries or Attorneys -In -Fact for purposes only of
executing and attesting bonds and undertakings and other writings obligatory in the nature thereof, and any such Power of Attorney or certificate bearing
such facsimile signature or facsimile seal shall be valid and binding upon the Company and any such power so executed and certified by such facsimile
signature and facsimile seal shall be valid and binding on the Company in the future with respect to any bond or understanding to which it Is attached.
I, Kevin E. Hughes, the undersigned, Assistant Secretary of Travelers Casualty and Surety Company of America, Travelers Casualty and Surety
Company, and St. Paul Fire and Marine Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of the Power of
Attorney executed by said Companies, which remains in full force and effect.
Dated this 15th day of July , 2024
�tytutq�r
IA9 FOyRO IOcotIl CCOSobt=l s µ;n 1
ty CC..:�21
S +f
�, .. �
� �� �o of Fa J9 t!, x
,&::� f /-
Kevin E. Hughes, Assi tant Secretary
To verify the authenticity of this Power of Attorney, please call us at 1-800-421-3880.
Please refer to tine above -named Attorney -in -Pact and the details of the hand to wlrich this Power of Attorney is attached.
CONTRACT 24-11
ATTACHMENT A
LIST OF PROPOSED SUBCONTRACTORS
RECEWED
JUL 15 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the proposed Subcontractors and the class of work to be performed by each. The
CONTRACTOR will be permitted to sublet a portion of the Contract, but shall perform with their
organization work amounting to at least thirty percent (30%) of the original Contract amount.
Work performed by the CONTRACTOR for any Bid Item that had been subcontracted will not be
included towards the thirty percent (30%) calculation.
If the CONTRACTOR shall sublet any part of this Contract, the CONTRACTOR shall be as fully
responsible to the CITY for the acts and omissions of their Subcontractor and of the persons either directly
or indirectly employed by their Subcontractor as they are by acts or omissions of persons directly
employed by themselves. All Subcontractors, if any, shall be listed in the spaces provided on the
Proposal Form and said list shall not be added to or altered without the written consent of the CITY.
Signed, final waivers of lien from the Subcontractors will need to be provided to the CITY prior to the
release of the final retai page to the CONTRACTOR.
When a Subcontractor and the class of work to be performed are not listed, it shall be considered that the
Bidder will perform the work themselves.
NAME OF PROPOSED
SUBCONTRACTOR
CLASS OR ITEMS OF WORK
Mo,6Q 16 Sea .I I n�
`Trlk-f i G CznjYb
PERCENT OF
CONTRACT AMOUNT
5,)s10
J• -7"1y
I hereby certify that the use of the name(s) of the abQ,y,% Shibcontractor(s) was with the knowledge and
consent of the said Subcontractors) �.•o�S�9 UCT/O,y'��,
G cjRP0T?4T ;OO
`F-; �-
ignature of Bidd ichael J. Maples re14c it SEAL
page 9'oil .�
CONTRACT 24-11
PROPOSAL
RECEIVED
'JUL 15 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
The undersigned will begin work as specified after award of the Contract and complete as specified.
I hereby certify that all statements are made in behalf of
Vinton Construction Corn
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of Wisconsin
a Partnership consisting of ; or
an individual trading as , ; of
the City of Two Rivers ; State of Wisconsin
That I have examined and carefully prepared this Proposal from the Plans and Specifications 1�61��1i1Vf31n,,,,
checked the same in detail before submitting this Proposal; that I have full authority to ° � Suc9iy�''%;
statements and submit this Proposal in (its) (their) behalf; and that said statements are true ��I �9$ 4�figT' CO
ignaturc. '
Michael 1. Magles / Presidciftk,,, t„„%%%%%%��,•``
(Title, if any)
Subscribed and sworn to before me this 15th day of �n,utl,' , 20 24
c` % •,
IF
pTAR
Notary Public, o her authorized to administer
._ .
op WISG�`�`�,
(Bidder should not add any conditions or qualifying statemeriSnt".(-hw Proposal as otherwise the Proposal
may be declared irregular as not being responsive to the Advertisement.)
Accompanying this Proposal is a Bid Bond in the amount of 5 % of the total amount of the Bid, as
called for hi the Official Notice to Contractors.
Page 12 of 12
RECEIVED
City i JUL 15 2024
EPT OF PUBLIC
U�
Cis h kos h DOSHKOSH, WISCONSINS
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
Please review the attached Department of Workforce Development Disclosure of OwnersNp form. If Item 3 on this
Disclosure of Owuersidp form applies to your company, you must complete the Disclosure of Ownership form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ow►iersl►ip form does NOT apply to your company, you must complete the
information below and upload this page in the appropriate location on Quest V-Bid.
CERTIFICATION
I certify by my signature below that Item 3 of the attached Disclosure of Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
ell RU,,,`pa�nrnrpq�
40
0 ti
a
��e
Name ' ro
L� SEAL
o r
Michael J. Maples,,'���''�ii,,,,u,u►��,`��`'",`,"•
Printed Name
President
Title
Vinton Construction Company
Company Name
July 15th, 2024
Date
1: \ Ungineering\Tracy Taylor\Public Works Contracts\Miscellaneous\Disclosure of ownership Fomi_2-1- Page 1 of 1
17.doca
City Hall, 215 Church Avenue t'.O. Box 1 130 Oshkosh, WI 54903-1130 htip://www.ci.oshkosli.wi.us
State of Wisconsin
Department of Workforce Development
Equal Rights Division
Disclosure of Ownership
The statutory authority for the use of this form is prescribed in Sections 66.0903(12)(d), 66.0904(10)(d) and 103.49(7)(d), Wisconsin
Statutes.
The use of this form is mandatory. The penalty for failing to complete this form is prescribed in Section 103.005(12), Wisconsin
Statutes.
Personal information you provide may be used for secondary purposes [Privacy law, s. 15.04(1) (m), Wisconsin Statutes].
(1) On the date a contractor submits a bid to or completes negotiations with a state agency, local governmental unit, or
developer, investor or owner on a project subject to Section 66.0903, 66.0904 or 103,49, Wisconsin Statutes, the
contractor shall disclose to such state agency, local governmental unit, or developer, investor or owner, the name of
any "other construction business," which the contractor, or a shareholder, officer or partner of the contractor, owns or
has owned within the preceding three (3)'years.
(2) The term "other construction business" means any business engaged in the erection, construction, remodeling,
repairing, demolition, altering or painting and decorating of buildings, structures or facilities. It also means any
business engaged in supplying mineral aggregate, or hauling excavated material or spoil as provided by Sections
66.0903(3), 66.0904(2), 103.49(2) and 103.50(2), Wisconsin Statutes.
(3) This form must ONLY be filed, with the state agency project owner, local governmental unit project owner, or
developer, investor or owner of a publicly funded private construction project that will be awarding the contract, if both
(A) and (B) are met.
(A) The contractor, or a shareholder, officer or partner of the contractor:
(1) Owns at least a 25% interest in the "other construction business," indicated below, on the date the contractor
submits a bid or completes negotiations; or
(2) Has owned at least a 25% interest in the "other construction business" at any within the preceding three
(3) years.
(B) The Wisconsin Department of Workforce Development (DWD) has determined that the "other construction
business" has failed to pay the prevailing wage rate or time and one-half the required hourly basic rate of pay, for
hours worked in excess of the prevailing hours of labor, to any employee at any time within the preceding three (3)
years.
Other Construction Business
Business Name
N/A
Street Address or P O Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
I hereby state under penalty of perjury that the information, contained In this document, is true and
accurate according to my knowledge and,bellef.
Print the Name of Authorized Officer
.�`�� ��ucTio.....
Michael J. Maples / President
.,°� r�5-'""-``•'i' "`r
Authorized Office
p
`0
F
e Signed
- M/2024
Corporation, Part ip or Stle Prop
shiF;1Lp ,
�c
Vinton Construction Company
.
�``•,
Street Address or P O Box
`• • . _ . ,.�`~
City
State
Zip Code
1322 33rd Street (P.O. Box 137)
`��,,,��.�°�
Two Rivers
WI
54241
If you have any questions call (608) 266-6861
ERD-7777 (R. 01/2011)
BID BOND #471935
RECEIVED
JUL 15 20 " CITY OF OSHKOSH
DEPT OF PUBLIC WORKS
Contract Number 24-11 (Sanitary Manhole Rehabilitation/Inflow InfiltMtidh(fZddbdh64i�'N6gram)
Date Bond Executed (Date of Contract or Later) 7/8/2024
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
Carl Bowers & Sons Construction Company Inc
N1844 Maloney Rd
Kaukauna, WI 54130
SURETY(IES) (Legal Name(s) and Business Address(es))
Merchants Bonding Company (Mutual)
PO Box 14498
Des Moines, IA 50306-3498
OWNER ('Legal Name and Business Address)
CITY OF OSHKOSH
215 Church Avenue
PO Box 1130
Oshkosh, Wisconsin 54903-1130
OBLIGATION
Type of Organization
Individual — Partnership
_K Corporation
State of Incorporation
Penal Sum of Bond
5% of bid amount
The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors,
and assigns to the Owner for the amount of the penal sum identified above if the Owner accepts the bid of this
Contractor within the time specified in the Bid documents or within such time period as may be agreed upon
between the Owner and the Contractor, and the Contractor shall fail to execute the Contract within five (5) business
days of written notice to the Contractor and Surety of Owner's intent to make a claim upon this Bond.
The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in
which the Owner may accept the Bid.
If the Contractor either enters into a contract with Owner in accordance with the terms of the Bid and gives such
bond(s) that may be specified in the Bidding documents for the faithful performance of the Contract and for the
prompt payment of labor, materials, and supplies furnished for the purpose thereof, or pays to the Owner the
difference between the amount specified in the Bid and such larger amount for which the Owner may in good faith
contract with another party to perform the work covered in such Bid, then the Surety and the Contractor shall have
no obligation under this Bond.
Page 1 of 2
Notice to the Contractor or Surety shall be deemed to have been given: (i) upon delivery to an officer or person
entitled to such notice, if hand delivered; or (ii) two (2) business days following deposit in the United States mail,
postage prepaid; (iii) upon delivery by a commercial carrier that will certify the date and time of delivery; or (iv)
upon transmission if by facsimile, e-mail, or other form of electronic transmission. Notices shall be provided to the
Owner, Surety, and/or Contractor at their address as specified on this Bond or to a facsimile, e-mail or other
electronic address that has been provided in writing to the other party to be used for this purpose.
The laws of the State of Wisconsin shall govern the interpretation and construction of this Bond. Winnebago
County shall be the venue for all disputes arising under this Bond. Any provision in this Bond that may conflict
with statutory or other legal requirement shall be deemed deleted herefrom and provisions conforming to the
statutory or other legal requirement shall be deemed incorporated herein.
CARL BOWERS & SONS CONSTRUCTION CO INC
Name of Principal/Contractor
Pe5
�t-r�
MERCHANTS BONDING COMPANY MUTUAL
Name of Surety
* 4 Y
Title Michael L. Tie (Attorne-In-Fact)��
l ei
Page 2 of 2
Bond #: 471935
BONDING COMPANY.
POWER OF ATTORNEY
Know All Persons By These Presents, that MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.,
both being corporations of the State of Iowa, d/b/a Merchants National Indemnity Company (in California only) (herein collectively called the
"Companies") do hereby make, constitute and appoint, individually,
Michael L Tiedt
their true and lawful Attorney(s)-in-Fact, to sign its name as surety(ies) and to execute, seal and acknowledge any and all bonds, undertakings,
contracts and other written instruments in the nature thereof, on behalf of the Companies in their business of guaranteeing the fidelity of
persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any actions
or proceedings allowed by law.
This Power -of -Attorney is granted and is signed and sealed by facsimile under and by authority of the following By -Laws adopted by the Board
of Directors of Merchants Bonding Company (Mutual) on April 23, 2011 and amended August 14, 2015 and adopted by the Board of Directors of
Merchants National Bonding, Inc., on October 16, 2015.
"The President, Secretary, Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and
authority to appoint Attorneys -in -Fact, and to authorize them to execute on behalf of the Company, and attach the seal of the Company thereto,
bonds and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof."
"The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney
or Certification thereof authorlAng the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the
Company, and such signature and seal when so used shall have the same force and effect as though manually fixed."
In connection with obligations in favor of the Florida Department of Transportation only, it is agreed that the power and aut hority hereby given to the
Attorney -in -Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction
contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department
of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of
its obligations under its bond.
In connection with obligations in favor of the Kentucky Department of Highways only, it is agreed that the power and authority hereby given
to the Attorney4n-Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner -
Department of Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation.
In Wdness Whereof, the Companies have caused this instrument to be signed and sealed this 8th day of July 2024 -
rep.rrrr •... .®d.
.•• ••. • . MERCHANTS BONDING COMPANY (MUTUAL)
.•°°�Q���O N44 �`'•. ; -* kk 'G •CQ•. MERCHANTS NAT[ONAi. BONDING, INC.
oy '®,%PO/?,. �®°; vO? (iPOiQ =�9, ® dib/a MERCHANTS NATIONAL INDEMN17Y COMPANY
Iri
v 2003 ; ,c�i �.Y 1933 �- C;
:� ,•/•� ey • BY
''•,.Rrrj�r`•♦,••`' •.�®�®.® dent
STATE OF iOWA President
COUNTY OF DALLAS ss.
On this 8th day of July 2024 before me appeared Larry Taylor, to me personally known, who being by me duly sworn
did say that he is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the
seats affixed to the foregoing instrument are the Corporate Seals of the Companies; and that the said instrument was signed and sealed in behalf
of the Companies by authority of their respective Boards of Directors. _
Penn! Miller
�
Commission Number 787952
o ® My Commission Expires
z
i0WA January 20, 2027
— 4
(Expiration of notary's commission
does not invalidate this instrument)
I, William Warner, Jr., Secretary of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC., do hereby
certify that the above and foregoing is a true and correct copy of the POWER -OF -ATTORNEY executed by said Companies, which is still in full
force and effect and has not been amended or revoked.
In Witness Whereof, I have hereunto set my hand and affixed the seal of the Companies on this 8th day of July 2024 .
TA
• y' to..
1:�f 0 - ;9% �1. -
: Z 4.4. . 1933 ' C ° Secretary
2003 1+®
PQA0018 (1l24) +•''"rr..•♦•••`' ••®.®...
RECENED
CONTRACT 24-11
ATTACHMENT A
LIST OF PROPOSED SUBCONTRACTORS
JUL 15 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the proposed Subcontractors and the class of work to be performed by each. The
CONTRACTOR will be permitted to sublet a portion of the Contract, but shall perform with their
organization work amounting to at least thirty percent (30%) of the original Contract amount.
Work performed by the CONTRACTOR for any Bid Item that had been subcontracted will not be
included towards the thirty percent (30%) calculation.
If the CONTRACTOR shall sublet any part of this Contract, the CONTRACTOR shall be as fully
responsible to the CITY for the acts and omissions of their Subcontractor and of the persons either directly
or indirectly employed by their Subcontractor as they are by acts or omissions of persons directly
employed by themselves. All Subcontractors, if any, shall be listed in the spaces provided on the
Proposal Form and said list shall not be added to or altered without the written consent of the CITY.
Signed, final waivers of lien from the Subcontractors will need to be provided to the CITY prior to the
release of the final retainage to the CONTRACTOR.
When a Subcontractor and the class of work to be performed are not listed, it shall be considered that the
Bidder will perform the work themselves.
NAME OF PROPOSED
SUBCONTRACTOR
Al A K
CLASS OR ITEMS OF WORK
I-'e2ZG✓c L
s .r �a/7'
Ira iq, i late /
PERCENT OF
CONTRACT AMOUNT
le) l
-5i"
I hereby certify that the use of the name(s) of the above Subcontractor(s) was with the knowledge and
consent of the said Subcontractor(s).
Page 9 of 12
T RECEIVED
I
i
JUL 15 2024
CONTRACT 24-11
PROPOSAL DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
The undersigned will begin work as specified after award of the Contract and complete as specified.
I hereby certify that all statements are made in behalf of
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of .,'S o 4?5 /�
a Partnership consisting of or
an individual trading as _ of
the City of ; State of
That I have examined and carefully prepared this Proposal from the Plans and Specifications and have
checked the same in detail before submitting this Proposal; that I have full authority to make such
statements and submit this Proposal in (its) (their) behalf; and that said statements are true and correct.
itle, if any)
Subscribed and sworn to before me this I S day of - 20
ajain?i &attn-�
Notary Public, or other authorized to administer ADAM CARL BOWERS
Notary Public
State of Wisconsin
(Bidder should not add any conditions or qualifying statements to this Proposal as otherwise the Proposal
may be declared irregular as not being responsive to the Advertisement.)
Accompanying this Proposal is a Bid Bond in the amount of —L % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 12 of 12
frJ "iri.y
c1ly
of
0Shkosh
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
RECEIVED
JUL 15 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Please review the attached Department of Workforce Development Disclosure of Ownership form. If Item 3 on this
Disclosure of Ownership form applies to your company, you must complete the Disclosure of Ownership form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ownership form does NOT apply to your company, you must complete the
information below and upload this page in the appropriate location on Quest V-Bid.
CERTIFICATION
I certify by my signature below that Item 3 of the attached Disclosure of Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
' 1 -d wars
Printed Name
,�Pce i a/N AT✓Ga liar
Title
44"1 Hsw /9 1 '15,009 6-e- a"I Ow
Company Name
Date
1: \ Engineering\Tracy Taylor\ Public Works Contracts\ Miscellaneous \Disclosure of Ownersldp Form_2-1- Page 1 of 1
17.doa
City Hall, 215 Church Avenue P.O. Box 1 130 Oshkosh, WI 54903-1 130 http://www.ci.oshkosh.wi.us
State of Wisconsin
Department of Workforce Development
Equal Rights Division
The statutory authority for the use of this form is prescribed in Sections 66.0903(12)(d), 66.0904(10)(d) and 103.49(7)(d), Wisconsin
Statutes.
The use of this form is mandatory. The penalty for failing to complete this form is prescribed in Section 103.005(12), Wisconsin
Statutes.
Personal Information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1) (m), Wisconsin Statutes].
(1) On the date a contractor submits a bid to or completes negotiations with a state agency, local governmental unit, or
developer, investor or owner on a project subject to Section 66.0903, 66.0904 or 103,49, Wisconsin Statutes, the
contractor shall disclose to such state agency, local governmental unit., or developer, investor or owner, the name of
any "other construction business," which the contractor, or a shareholder, officer or partner of the contractor, owns or
has owned within the preceding three (3) years.
(2) The term "other construction business" means any business engaged in the erection, construction, remodeling,
repairing, demolition, altering or painting and decorating of buildings, structures or facilities. it also means any
business engaged in supplying mineral aggregate, or hauling excavated material or spoil as provided by Sections
66.0903(3), 66.0904(2), 103.49(2) and 103.50(2), Wisconsin Statutes.
(3) This form must ONLY be filed, with the state agency project owner, local governmental unit project owner, or
developer, investor or owner of a publicly funded private construction project that will be awarding the contract, if both
(A) and (B) are met.
(A) The contractor, or a shareholder, officer or partner of the contractor:
(1) Owns at least a 25% interest In the "other construction business," indicated below, on the date the contractor
submits a bid or completes negotiations; or
(2) Has owned at least a 25% interest in the "other construction business" at any time within the preceding three
(3) years.
(B) The Wisconsin Department of Workforce Development (DWD) has determined that the "other construction
business" has failed to pay the prevailing wage rate or time and one-half the required hourly basic rate of pay, for
hours worked in excess of the prevailing hours of labor, to any employee at any time within the preceding three (3)
years.
Other Construction Business
Business Name
NIA
Street Address or P0 Box
City
State
Zip Code
Business Name
Street Address or P 0 Box
City
State
Zip Cade
Business Name
Street Address or P 0 Box
City
State
Zip Code
Business Name
Street Address or P O Box
City
State
Zip Code
I hereby state under penalty of perjury that the Information, contained in this document, is true and
t d' t knowled a and bellef
accura a accor to o m
Print the Name of Authorized Officer
Authorized Officer Signature
Date Signed
-/Z0�
Corporation, Partnership or Sale Proprietorship Name ® soeo ��l57ri^wc��ve�
s
Street Address or P O Box �0 t®✓Te'Y
City q
��Gt �i'A t�v7
State
Z J ;el/ 0
If you have any questions call (608) 266-6861
ERD-7777 (R. 01/2011)
Contract Number Contract 24-11
Date Bond Executed (Date of Contract or Later) 7/8/2024
PRINCIPAL/CONTRACTOR (Legal Name and Business Address)
De Groot, Inc.
4201 Champion Rd.
Green Bay, WI 54311
SURETY(IES) (Legal Name(s) and Business Address(es))
Employers Mutual Casualty Company
1815 S Meyer Rd.
Oakbrook Terrace IL 60181
OWNER (Legal Name and Business Address)
CITY OF OSHKOSH
215 Church Avenue
PO Box 1130
Oshkosh, Wisconsin 54903-1130
OBLIGATION
RECEWED CITY OF OSHKOSH
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Type of Organization
Individual _ Partnership
X Corporation
State of Incorporation
Wisconsin
Penal Sum of Bond
5% of Bid
The Contractor and Surety, jointly and severally, bind themselves, their heirs, executors, administrators, successors,
and assigns to the Owner for the amount of the penal sum identified above if the Owner accepts the bid of this
Contractor within the time specified in the Bid documents or within such time period as may be agreed upon
between the Owner and the Contractor, and the Contractor shall fail to execute the Contract within five (5) business
days of written notice to the Contractor and Surety of Owner's intent to make a claim upon this Bond.
The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in
which the Owner may accept the Bid.
If the Contractor either enters into a contract with Owner in accordance with the terms of the Bid and gives such
bond(s) that may be specified in the Bidding documents for the faithful performance of the Contract and for the
prompt payment of labor, materials, and supplies furnished for the purpose thereof; or pays to the Owner the
difference between the amount specified in the Bid and such larger amount for which the Owner may in good faith
contract with another party to perform the work covered in such Bid, then the Surety and the Contractor shall have
no obligation under this Bond.
Page 1 of 2
Notice to the Contractor or Surety shall be deemed to have been given: (i) upon delivery to an officer or person
entitled to such notice, if hand delivered; or (ii) two (2) business days following deposit in the United States mail,
postage prepaid; (iii) upon delivery by a commercial carrier that will certify the date and time of delivery; or (iv)
upon transmission if by facsimile, e-mail, or other form of electronic transmission. Notices shall be provided to the
Owner, Surety, and/or Contractor at their address as specified on this Bond or to a facsimile, e-mail or other
electronic address that has been provided in writing to the other party to be used for this purpose.
The laws of the State of Wisconsin shall govern the interpretation and construction of this Bond. Winnebago
County shall be the venue for all disputes arising under this Bond. Any provision in this Bond that may conflict
with statutory or other legal requirement shall be deemed deleted herefrom and provisions conforming to the
statutory or other legal requirement shall be deemed incorporated herein.
De Groot, Inc.
Name of Principal/Contractor
Title President
OP
SF;AL
Employers Mutual Casualty Company
Name of Surety
Title Attor ey-In-Fact
Page 2 of 2
P.O. Box 712 • Des Moines, Iowa 50306.0712
*emc
INSURANCE
POWER OF ATTORNEY APPOINTING INDIVIDUAL ATTORNEY -IN -FACT
KNOW ALL MEN BY THESE PRESENTS, that:
1. Employers Mutual Casualty Company, an Iowa Corporation
2. EMCASCO Insurance Company, an Iowa Corporation
3. Union Insurance Company of Providence, an Iowa Corporation
4. Illinois EMCASCO Insurance Company, an Iowa Corporation
5. Dakota Fire Insurance Company, a North Dakota Corporation
6. EMC Property & Casualty Company, an Iowa Corporation
1
hereinafter referred to severally as "Company" and collectively as "Companies", each does, by these es nts, make, cMUR
int:
Sherry L Hendricks �Q(�
its true and lawful attorney -in -fact, with full power and authority conferred to sign, seal, and execute th�ei and u
Any and All Bonds
and to bind each Company thereby as fully and to the same extent as if such instruments were signed by the duly authorized officers of each such Company, and all
of the acts of said attorney pursuant to the authority hereby given are hereby ratified and confirmed.
AUTHORITY FOR POWER OF ATTORNEY
This Power -of -Attorney is made and executed pursuant to and by the authority of the following resolution of the Boards of Directors of each of the Companies at the
first regularly scheduled meeting of each company duly called and held in 1999:
RESOLVED: The President and Chief Executive Officer, any Vice President, the Treasurer and the Secretary of Employers Mutual Casualty Company shall have
power and authority to (1) appoint attorneys -in -fact and authorize them to execute on behalf of each Company and attach the seal of the Company thereto, bonds
and undertakings, recognizances, contracts of indemnity and other writings obligatory in the nature thereof; and (2) to remove any such attorney-m-fact at any time
and revoke the power and authority given to him or her. Attorneys -in -fact shall have power and authority, subject to the terms and limitations of the power -of -attorney
issued to them, to execute and deliver on behalf of the Company, and to attach the seal of the Company thereto, bonds and undertakings, recognizances, contracts of
indemnity and other writings obligatory in the nature thereof, and any such instrument executed by any such attorney -in -fact shall be fully and in all respects binding upon
the Company. Certification as to the validity of any power -of -attorney authorized herein made by an officer of Employers Mutual Casualty Company shall be fully and in all
respects binding upon this Company. The facsimile or mechanically reproduced signature of such officer, whether made heretofore or hereafter, wherever appearing upon
a certified copy of any power -of -attorney of the Company, shall be valid and binding upon the Company with the same force and effect as though manually affixed.
IN WITNESS THEREOF, the Companies have caused these presents to be
22nd day of September , 2022 ,
Seals
`:00'INSUR�'•, `� LOMP4ry '.
,,,,
..`�` ` $' C4
pR'.,
`O
S."= : 9�f
`,Q�'..OPPQq,�I.
.
Q 4J
y
=a SEAL 'q= =-': 1863
1953
IOWA
,5UPa,y�F'., `NSURAN�''.
0 '.
�U40.C�PP nR,i1f COro:. � ``Fay pP40Rgt �Cp9'
`:'�U;UA
UR4 r�rs (:
SEAL z= :° SEAL ='z:;�
-`�P`�coRP
SEAL
o
_ o_
�OPKO
KATHY LOVERIDGE
yy
LCwvftaton Nwkw 780769
myocl
for each by their officers as shown, and the Corporate seals to be hereto affixed this
ott R. Jean, P dent & CEO Todd Strother, Executive Vice President
of Company 1; irman, President Chief Legal Officer & Secretary of
& CEO of Comp ies 2, 3, 4, 5 & 6 Companies 1, 2, 3, 4, 5 & 6
On this 22nd day of September 2022 before me a Notary Public in and for the State
of Iowa, personally appeared Scott R. Jean and Todd Strother, who, being by me duly sworn,
did say that they are, and are known to me to be the CEO, Chairman, President, Executive
Vice President, Chief Legal Officer and/or Secretary, respectively, of each of the Companies
above; that the seals affixed to this instrument are the seals of said corporations; that said
instrument was signed and sealed on behalf of each of the Companies by authority of their
respective Boards of Directors; and that the said Scott R. Jean and Todd Strother, as such
officers, acknowledged the execution of said instrument to be their voluntary act and deed,
and the voluntary act and deed of each of the Companies.
My Commission Expires October 10, 2025.
CERTIFICATE
q-6," 4V_.(CJL G lJ
Notary Publi6 in and for the State o 0t1
I, Ryan J. Springer, Vice President of the Companies, do hereby certify that the foregoing resolution of the Boards of Directors by each of the Companies, and
this Power of Attorney issued pursuant thereto on 22nd day of September , 2022 , are true and correct and are still in full force and effect.
In Testimony Whereof I have subscribed my name and affixed the facsimile seal of each Company this 8th day of July, 2024
4' Vice President
7854 (9-22) B027308-NA D8452 957 A 000000 "For verification of the authenticity of the Power of Attornev you may call (515) 345-7548."
CONTRACT 24-11 RECEIVED
ATTACHMENT A JUL 15 2024
LIST OF PROPOSED SUBCONTRACTORS DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Pursuant to Section 66.29(7), Wisconsin Statutes, the Bidder, as part of this Proposal, submits this full and
complete list of all the proposed Subcontractors and the class of work to be performed by each. The
CONTRACTOR will be permitted to sublet a portion of the Contract, but shall perform with their
organization work amounting to at least thirty percent (30%) of the original Contract amount.
Work performed by the CONTRACTOR for any Bid Item that had been subcontracted will not be
included towards the thirty percent (30%) calculation.
If the CONTRACTOR shall sublet any part of this Contract, the CONTRACTOR shall be as fully
responsible to the CITY for the acts and omissions of their Subcontractor and of the persons either directly
or indirectly employed by their Subcontractor as they are by acts or omissions of persons directly
employed by themselves. All Subcontractors, if any, shall be listed in the spaces provided on the
Proposal Form and said list shall not be added to or altered without the written consent of the CITY.
Signed, final waivers of lien from the Subcontractors will need to be provided to the CITY prior to the
release of the final retainage to the CONTRACTOR.
When a Subcontractor and the class of work to be performed are not listed, it shall be considered that the
Bidder will perform the work themselves.
NAME OF PROPOSED PERCENT OF
SUBCONTRACTOR CLASS OR ITEMS OF WORK CONTRACT AMOUNT
1 �Ji
A4 S "
G✓'en + Lo,V s
cevlcn�t:
-4okci) �
/1ICD.rILdl
I hereby certify that the use of the name(s) of the above Subcontractor(s) was with the knowledge and
consent of the said Subcontractor(s).
Signature of Bidder
Page 9 of 12
CONTRACT 24-11
PROPOSAL
RECEIVED
JUL 15 2024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
The undersigned will begin work as specified after award of the Contract and complete as specified.
I hereby certify that all statements are made in behalf of
De Groot, Inc.
(Name of Corporation, Partnership, or Person Submitting Bid)
a corporation organized and existing under the laws of the State of Wisconsin
a Partnership consisting of
an individual trading as
the City of
State of
or
. of
That I have examined and carefully prepared this Proposal from the Plans and Specifications and have
checked the same in detail before submitting this Proposal; that I have full authority to make such
statements and submit this Proposal in (its) (their) behalf; and thAmw=
Signature
President
(Title, if any)
Subscribed and sworn to before me this 15 day of J my 2024
DY
\OTARRk
CN ary Public, or ot14r authorized t dminister _
OP
(Bidder should not add any conditions or qualifying statem,t��9`Proposal as otherwise the Proposal
may be declared irregular as not being responsive to the Advertisement.)
Accompanying this Proposal is a Bid Bond in the amount of 5 % of the total amount of the Bid, as
called for in the Official Notice to Contractors.
Page 12 of 12
city
0�
Oshkosh
TO: ALL CONTRACTORS
FROM: ENGINEERING DIVISION OF
CITY OF OSHKOSH DEPARTMENT OF PUBLIC WORKS
SUBJECT: DISCLOSURE OF OWNERSHIP FORM
RECEIVED
JUL 15 Z024
DEPT OF PUBLIC WORKS
OSHKOSH, WISCONSIN
Please review the attached Department of Workforce Development Disclosure of Ownership form. If Item 3 on this
Disclosure of Ownership form applies to your company, you must complete the Disclosure of Ownership form and
upload in the appropriate location on Quest V-Bid.
If Item 3 on the Disclosure of Ownership form does NOT apply to your company, you must complete the
information below and upload this page in the appropriate location on Quest V-Bid.
CERTIFICATION
I certify by my signature below that Item 3 of the attached Disclosure of Ownership form does NOT apply to my
firm, or a shareholder, officer, or partner of my firm.
Mark De Groot
Printed Name
President
Title
De Groot, Inc.
Company Name
7/12/24
Date
l:\Engineering\ Tracy Taylor\ Public Works Contracts\ Miscellaneous\Disclosure of Ownership Form-2-1- Page 1 of 1
17.docx
City Hall, 215 Church Avenue P.O. Box 1 130 Oshkosh, WI 54903-1 130 http://www.ci.oShkosh.wi.us
State of Wisconsin
Department of Workforce Development
Equal Rights Division
Disclosure of Ownership
The statutory authority for the use of this form is prescribed in Sections 66.0903(12)(d), 66.0904(10)(d) and 103.49(7)(d), Wisconsin
Statutes.
The use of this form is mandatory. The penalty for failing to complete this form is prescribed in Section 103.005(12), Wisconsin
Statutes.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1) (m), Wisconsin Statutes).
(1) On the date a contractor submits a bid to or completes negotiations with a state agency, local governmental unit, or
developer, investor or owner on a project subject to Section 66.0903, 66.0904 or 103.49, Wisconsin Statutes, the
contractor shall disclose to such state agency, local governmental unit, or developer, investor or owner, the name of
any "other construction business," which the contractor, or a shareholder, officer or partner of the contractor, owns or
has owned within the preceding three (3) years.
(2) The term 'other construction business" means any business engaged in the erection, construction, remodeling,
repairing, demolition, altering or painting and decorating of buildings, structures or facilities. It also means any
business engaged in supplying mineral aggregate, or hauling excavated material or spoil as provided by Sections
66.0903(3), 66.0904(2), 103.49(2) and 103.50(2), Wisconsin Statutes.
(3) This form must ONLY be filed, with the state agency project owner, local governmental unit project owner, or
developer, investor or owner of a publicly funded private construction project that will be awarding the contract, if both
(A) and (B) are met.
(A) The contractor, or a shareholder, officer or partner of the contractor:
(1) Owns at least a 25% interest in the "other construction business," indicated below, on the date the contractor
submits a bid or completes negotiations; or
(2) Has owned at least a 25% interest in the 'other construction business" at any time within the preceding three
(3) years.
(B) The Wisconsin Department of Workforce Development (DWD) has determined that the 'other construction
business" has failed to pay the prevailing wage rate or time and one-half the required hourly basic rate of pay, for
hours worked in excess of the prevailing hours of labor, to any employee at any time within the preceding three (3)
years.
Other Construction Business
Business Name
NIA
Street Address or P O Box
City
State
Zip Code
Business Name
N/A
Street Address or P 0 Box
City
State
Zip Code
Business Name
N/A
Street Address or P 0 Box
City
State
Zip Code
Business Name
N/A
Street Address or P O Box
City
State
Zip Code
I hereby state under penalty of perjury that the information, contained in this document, is true and
accurate arrnrelinn to my knowledne and belief_
----------- -- --------------- - ------ --
Print the Name of Authorized Officer
Mark De Groot
Authori ffice Si atu
Date Signed
* �
17/15/24
Corporation, artnership or Sole Proprietorship Name
De Groot, Inc.
Street Address or P O Box
City
State
Zip Code
4201 Champion Rd.
Green Bay
WI
54311
If you have any questions call (608) 266-6861
ERD-7777 (R. 01/2011)