Agenda

UNITED STATES FIRE INSURANCE COMPANY
1209 ORANGE STREET, WILMINGTON, DELAWARE 19801

STATEMENT OF ASSETS, LIABILITIES, SURPLUS AND OTHER FUNDS

individual Acknowledgement

State of
County of

On this day of , 20 , before me personally came

to me known and known to me to be the individual(s) who executed the foregoing instrument, and
acknowledged that___he____ executed same.

Notary Public
My commission expires

Limited Liability Company/Partnership Acknowledgement

State of New York

County of Warren

On this 12th day of ___ February , 20 __19 _, before me personally
came JOU] R Kendor a member, manager or general

L.

Bidder and Surety, jointly and severally, bind
themselves, their heirs, executors, administrators,
successors, and assigns to. pay to OWNER upon
default of Bidder the penal sum set forth on the face
of this Bond.

BID BOND
PENAL SUM FORM

BIDDER (Naine and Address):
Kenyon Pipeline Inspection, LLC
68 Park Road
Queensbury, NY_ 12804

.ETY (Name-and Address of Principal Place of Business):
United States Fire Insurance Company
305 Madison Avenue

Morristown, NJ_ 07960

OWNER (Name and Address):
City of Nashua
__229 Main Street

Nashua, NH_ 03061

BID
BID DUE DATE: February 12, 2019
PROJECT (Brief Description Including Location);
2019 CIPP Lining Project
1FB1087-021219

LIST OF SUBCONTRACTORS
(to be submitted after bid opening)

LIST OF SUBCONTRACTORS
(to be submitted with bid)

The name and address of each subcontractor who will be paid at least five percent (5%) of the prime
contractor's total bid shall be listed below. To be deemed a responsive bid, this form must be submitted
even if no subcontractors are required to be listed. In that case, the bidder should state “None” (or similar
language stating that no subcontractors need to be listed) in the space below. (Refer to General Condition
6.09.H)

By:

(Signature of joint ventured partner -- attach evidence of authority to sign)

Name (typed or printed):

Title:

Business Address:

Phone No.: Fax No.:

Address for receipt of official communications:
68 Park Road

Queensbury, NY 12804

(Each joint ventured must sign. The manner of signing for each individual, partnership and
corporation that is a party to the joint venture should be in the manner indicated above).

BF 6 of 8

A Corporation
Corporation Name: _Kenyon Pipeline Inspection, LLC (SEAL)

Date and State of Incorporation: _ 9/14/2011 New York State

List of Executive Officers

Name Title
Jason R. Kenyon CEO
Joshua R. Kenyon President

a ye a Liability): Limited Liability

\ (Signature -- attach evidence of authority to sign)

Name (typed or printed): _ Jason R. Kenyon
Title: CEO 7) (Corporate Seal)

Attest: CBG CC —
/

Ciknature of Corporate Secretary)

Business Address: 68 Park Road Queensbury, NY 12804

An Individual

Name (typed or printed):

By: (SEAL)
(individual's Signature)
Doing business as:

Business address:

Phone No.: Fax No.:

A Partnership

Partnership Name: (SEAL)

Date and State of Organization

Names of Current General Partners

Name Title

Type of Partnership
[] General [] Publicly Traded
[] Limited [[) Other (describe):

By:

(Signature of General Partner ~ attach evidence of authority to sign)

Name (typed or printed):

Business address:

8.01 The following documents are attached to and made a condition of this Bid:
A. Bid Form;
B. Bid Bond;

C. A tabulation of Subcontractors, Suppliers and other individuals and entities required to be
identified in this Bid; and

Dz Construction Contractor's Qualification Statement.

9.01/ Communications concerning this Bid shall be addressed to:
(Contractor's mailing address to be filled in by Bidder)

Kevin Mitchell
68 Park Road Queensbury, NY 12804
518-832-4070