OWNERSHIP/PERSONNEL CHANGE FORM Teoma "*' Jack Daniel's Construction, Inc. Pe 42/09/2013 | 7 Rina en ion eer Sa > Aaa Tanai Tx ae Tp Te a7 9902 Personnel S Riana Jackson 7 Coven See 7 me . ‘Sree Address cy ‘San Angelo [ Vie or Poston Member, Manager, Parmer, Sharcolde, Direc, Offer Enplovesy ‘OP/Employee cna Tana MMSE NS” Merril Jessop MaKe Rayo TET Jessop 7. Geng Ip Sine r RZ Sue Ata Gi fee Zi al Rd San Angelo ix 76204 “ie o Poston (Membei, Manage, Parnes, Sharcholler, Disco, Tic WGN er] 7 Goverment 1D Sate es Az eae Sua Adres ny Bid. ‘San Angelo "rcent | 1. ile or Pasion (herb, Manage, Farmer, Sharehe ler, Dieclon OTH, Miaaenam Ton ‘Ore Sei es la tee Johrison | & Social Say Nbr] o Rsstaunl Aides Stes ASHES 1 10 § Central St | ©” Colorado City “az | 786021 Teena Tecer [TT Rain iene Mae, Pt Sari, ss ORE OT peas TER Emmet Tae parang TSTMS essop se of Ta Naar Paes cases ar eBreat ———— z i 7 asa Fete Ais SHS Ades oy Sa a ‘Ponderosa Grants NM. 87020 ogre rear | THES ai a, tr. Swen TR ORS TPQ Er noyeg 12 Mave you competed the criminal backround check during the let 440 days? Yes] No : (Each person sted mast include a copy of hicher background check receipt with his form 15, Have you ever been convicted of felony ora misemeanor, or carey havea felony harge pending? Yen CV No BL (Use etttonel paper vee) ye, ea hat charge whieh court regal eel eweawer "VES" coon has been vealed, pardoned. expe dass, pened, hd ns weet a ze td ar ou leh hove been restored. "declare, under penal of pry ha copies of 5 orginal, 'nformaton provided herein sue fry own hnosledge. 1 Str cert that all tached documents are ni and accurate Fink Ti Teste OnticerDirecroterewonageiPerner OonicerDirector Member ManageePariner ovase ona Vist our wobsito: ww aoc gov OmentipPerscnne Change Page 22nomex Orvice Too W. WasIINGTONST. SUITETOS puorwex Az 850072812 (sit) sb: 1sisor Az Tou-Pane ESTPMY AZROC (-877-692.9762) Teeson OrnIce ‘400 w, CongnEss, STE. 212 srucson, AZ 5001-1331 (S20) or8-5Ms ARIZONA REGISTRAR of CONTRACTORS OWNERSHIP/PERSONNEL CHANGE FORM INSTRUCTIONS ‘MAIL TO: P.O. BOX 6688 PHOENIX.AZ 85005-6688 Faxed or emailed copies are not accepted. ser :8.5.$ 32-10, aeese sail adie thesis of my chang in cmap intron SS te applicant fa corporation, 29 er. RID ees Sl Mode ns nd edt oe ese, ese ae the names and sss of ary te emia pen afin he detente OWES FEROA ANE rn mT FN SOE beneficial interest company name: The company nae mae tha peas nthe Hes ane ai mame nde wih Ne contecting business operates 4, Federal Tax Idetieation Number (TIN): Prove aid Tax Idetieaton Numer CN) 4 Adaons Transaction Privilege Tax Number (FP: Pov vad aan TeamactionPiviege Tax Nuns arn, | License Thetcese umber) ised in sc he cmpany i udating te ones partners, fees, ison members ormanagers. All Ticennes sued to the company must be Usted. Personnel The personel iste shall nchue the fllowing othe Quatyng Paty (QP). 2 tea parmesship, ll partners Ea een, cers sean, errr (eqs, rece dl aves EE + excorperaon th en pemagt e alOvnes oF 25% of more na Manger-manged LLCS all memes nt owners of 259% 08 more ina Memnber-masaged LLC. ina Membormenatd LLC, sore, rove mop semen a ss wan te dy o-yopraons om 2 ‘sped, roe Ped andrtiriedafcavt sting who ra the de)-‘oday operation fo Be LLC «5 tfownerhip i hele by anther enity, writ the fll egal ame ofthe business entity S_name Fist, Mil, Lt) The oll leg mle nd as rane ares. he indie hs no mie site "None" IE {he mali oly has aidate iia, write "Only fier dhe sits Ge ateor Births A dt Bi for each invita st be povded_ ARS. 32-1122 prohibits amor fem beings individ owner, parte, aM ene oie, member or Qualifying Party on a contractor's eens se Goverment ID Site /Wamber: Wie th ste ing te 1D andthe 1D sur Typ the Goverment ID wb AEE issued a ereexngacsport Please submits cear copy ofthe. Example: A7./ DI24S678 ._Socat Security Number Paani to AS. 9§2530.25518 425319 the ROC mut lle och sano The ROC wil not we Soci Secaity Number Faron Own sly Lined Labi Company, Corporatio PETES P. ne be “x dentificnion Number. 1h. Residential Address: Write the compite residential adres, ncading iy, state and ip code, vo,_percent Ownership: Wiehe pret oomeriip-Tx owner erent fr a perooel ms inal 100%, Pussy wade compan met be nied 11. Title or Position: Write the tite ofthe person 12, Have you complete the criminal background check doring the ast 440 day? Chest eo, plese complete the criminal Haye you compte ong nam. The mia ened heck is maa rmial Rk "This backround Sick mt bb 9 dy ero Stan Each pessoa ised mut icidea copy of iserbecgreund check rsp wih tis 1. ave you cer been conited oa felony ora misdemeanor, currently have ony args pening CHASES! 2 tyes, desribe Fave you ever beet omc nasa tenure othe Sout he space prove, (Us atonal pape meds. An officer, Director, Merber, Manager o Part mut sign the fom, Origin! slemtues we reine corporins nd LLCs mus prove viene ht he Arizona Comoro Commision Ds SENG MAT ownershipfpersoanel change. Seer vette approved emoied ates wth he Alora Corporation Comision’ sd en AST within ys) printout from the Sb pte mic’ s webshe showing he Ble saber, al persone! and te Sats of goo string, ese make copes o his frm to accommodate more persoanel, ROC forms will only be aceePie RoLaee 63 Vis our website: www 2270¢-004 ‘Ownestinernoma! Change Page 1012 Be eee nes see een esee se teee ce eee eeeDecember 17, 2013, Jack Daniel's Construction Ine PO Box 842639 Hildale, UT 84784-2639 Re: Return of Officer change form for License A.28S604-C Dear Contractor ‘Your Officer Change Form has been returned for the following reason(s) LX] Parties listed on the license must match those listed at the AZ. Corporation Commission, Please provide documents stamped by the Corporation Commission for the amendments. James Barlow is listed with the Corporation Commission. [X] Frank Johnson and Emest Jessop needs to do the background check, See enclosed When a Corporation or LLC or Partnership is to be listed as an Owner or Member of a license an authorized signer isto be named. Information required to be provided for the named authorized signer is the same as an officer or member. | ‘The Officer Change form has not been filled out completely or accurately. Additional information is, needed, Full legal names including firs, middle, last, ancl generation (if it applies) must be ineluded for each officer, member, partner or owner. ‘The date of birth is required for each officer, member, partner or owner{ ‘The percentage of ownership for each officer, member, parter or owner is requited.[ ] ‘The felony question must be answered for each officer, member, partner or owner. LJ Official titles are required for each officer, member, partner or owner. Information provided is not legible] Information provided is not complete Sincerely, isi Christina Owen Christina Owen, Administrative Assistant IIL Phone: (602) 771-6732 Fax: (602) 542-7852 ist our webste at: www azzoc gov ReL267 413license exception report Page 1 of | Results for license: 285604 Contractor: Jack Daniel's Construction Inc DBA (if any): Class: AC Narrative: General Engineering Restriction: Item [Condition [Contact Type [CORPORATION (Standard Bond {$5,000.00 IRF Bond [FEIN es |Corp Number IF17711772 Email address jackdanielsinc@gmail.com [TPT Number First Possible Issue Date }06/14/2013 KIL QP Name [Ernest Milward Jessop Primary QP Name _|[Ernest Milward Jessop lowner count 2 Final approval (07/15/2013 "i 1045 W. Utah Ave #2 Hildale UT 84784 Phone (855) Public Address See onn (655) IMail Address bse a ere Hildale UT 84784-2639 Phone (855) hitp:/az.gov/ivrx/license_exception.cfm 7/15/2013PENDING / NEW QUALIFYING PARTY APPLICATION CONTRACTOR, \ Jat k Jawuels mst yu Js fa S Bees CLASS: bh RECEIVED a 85 lt otf LIC#_ REVIEWED BY pee - : Initial/Date (NAME AVAILABILITY — a BANKRUPICY Hee ——“t ay a cone Os { 20DAY POSTING ASSUMPTION MISDEMEANOR __l —— 1127 PERCENTAGE APPLICATION QP RESIGN ‘CBME: GooncelAie | [Reet poems | [omelet — INACTIVE STATUS TRADE: ae ‘Workers’ Comp | | Piewe I ‘BK Documents ee Sele Wasa a Coat aa RECOVERY PAID CONSUMER BOND SCREENS ‘Add Company, ‘Add Personnel to Owners Link “] | Add BOB to each person History Reports st appliable Bali (Mega Sear i | Add Credential ‘Add TPT & EIN # “Add SSN to each person NASCLA “Assign Reviewer “Aad Partnership, Corp or LLC number ‘Add Bond Fe ACC “ad Wark Order far ees “Rai QF exedental © PP Ada RF bond applicable “Raa Noes ‘Add/update mail address “Add QP under Sup. Tab “Add personnel to Key fe {cemove Ata: ine) = Management Hae et . bee }2- i OIE fe Paes Quokn® i518 Na Conpiouss :ATT: MATHACIE rors : : ‘21. Have: ae YOu ever reel clan fo contmcting wikoata Tanna? yes, when end where ae 22, Have you ever beea ana ponractors License Issued by Artana or aay Ocha saisT eS) ‘tyes, state : A2. Hoeone eats Stdninded.tieenso# A-1 43309 license name. 2 Tne SG alates (oertl Gepcadasens - Hye, which teense) -14 320 — Mit are te coent censuses) Gasperdll Lor Noo~Rentiont what was the caus ofthe discipline Quit doce boyeneas” luemse rot remesceak es 7a} 2. " ileal TY Ronit en 7 ree nd eo Cai ecg Thro decker lacus nd stereo ctngScedes ‘25, Have you ever been convicted of felony or Rave a felony charge pending? vs) pe, you are regret complete and oubmit the Criminal Hor Dlosre Packet hi tained one ei Dr oo awit sal Towarropred answer YES" a conve uated pardoned expunged dmed appealed lied a tndesgnted or othervite reduced or your cl rights hove een reared. You wil ented tn Meher han he intel Hay roe ng nate 26, Have you ever been convicted ofa misdemeanr? tyes, when what. 721. Have you ever been’ in paytacat of any ofthe following: tate or federal Income taxes, payroll ves ‘withholding, social seeuity, unemployment or workers’ compensation? “fv, ettach a detailed explanation and provide & peymontschatule, f applicable and Cerifloate of Good Standing from the Arizona Department of Revere. certify that {have reviewed the eatie contents of this application aod all statement In this spplleation, including all supplemiontary statements attacked hereto, are true and accar falsification of any information on this application isn violation ofthe Arizona Criminal Code inf ‘Title 13, Chapter 27, Kanderstand that pursuant to ALS, §§ 32-11S4(A}6\20) & 32-1122(D) pt Is eaese for denial ofthis applleation and cause for discipline of ROC tleenses. 1 ackuowledge that Lam a Person named oa ths license forthe parposes and duties ofall Reg incinding, but not Umited to, A.RS, §§ 32-1122, 32-1139(8) & 32-1154, ‘These purposes and duties arising out of or relating to agreements that were entered tnto, monies received, or work performed while Tam nained ‘thls Heenges T understand that because A.RS. § 32-1155(A) eatabllshes a two-year period forthe filing of complaints, these purposes and duties continue for up to two years after I disassociate from this license, Ernest Millward JessopLupe Valenzue From: Lupe Valenzuela Sent: Wednesday, July 10, 2013 12:18 PM To: "Rebecca Meza Subject: RE: Jack Daniel's Construction Inc P#285604 ‘Thank you Rebecca, | will take care of this. Lupe M. Valenzuela Arizona Registrar of Contractors From: Rebecca Meza [mailto:rebeccamez@azcic.com] Sent: Wednesday, July 10, 2013 10:50 AM To: Lupe Valenzuela; tiltonj@jackdanietsinc.com ‘Subject: Jack Daniel's Construction Inc P#285604 Hello Lupe, Per Janna she said to send this correction to Natalie's attention which Brad hand delivered in on June 26th, although he did not stamp it. But this is the form Emest did send right back, I hope it can be accepted. It would be appreciated. Thank you Rebece - Original Message --—— Date: Wed, 10 Jul 2013 10:55:06 -0700 From:azinfo@azcle.com To:rmg ‘This E-mail was sent from "PEX" (Agicio MP C3500) Scan Date: 07.10.2013 10:55:06 (-0700) Queries to: azinfo@azcic.comRE; RE: PH 285604- Jack Daniels Construction Inc 1 of2 Subject: RE: RE: Pf 285604- Jack Daniels Construction Inc From: Tilton Johnson Date: Wed, 26 Jun 2013 19:34:48 +0000 ‘To: Rebecca Meza Please see the attached file. “Thanks for your help Tilton Johnson Jack Deniel's Construction, Inc Acsounting & Compliance Phone. 855.855:0007 Ext 103 Fa. 055-855.0008 Emi Stoei@jackdariie.com From: Rebecca Meza [malto:rebeceamez@azele.com] Sent: Wednesday, June 26, 2013 10:26 AM Subject: Fwd: RE: PH 285604- Jack Daniels Construction Inc Good Morning Tilton, Tjust got this back from Janna, so go ahead and have Ernest answer the 7 and you can send to me if you like, and I can have it hand delivered so that we can get a stamped received copy that they received it. Thank ya rebecca Original Message- ‘Subject:RE: P# 285604- Jack Daniels Construction Inc Date: Wed, 26 Jun 2013 09:06:14 -0700 From:Janna Yaw To:'Rebecca Meza’ Hi Rebecca, Yes, have him fix it if it's wrong & send it back attention to Natalie, Im not sure who's going to get this file yet. -Janna From: Rebecca Meza [mallto:rebeccamez@azc.com] ‘Sent: Wednesday, June 26, 2013 9:05 AM To: Janna Yaw ‘Subject: Fwd: P# 285604- Jack Daniels Construction Inc ‘Good Morning Miss Janna, 7/9M2013 10:45 AMACORD,__ CERTIFICATE OF LIABILITY INSURANCE See 05/01/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLicies BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUGER, AND THE CERTIFICATE HOLDER. | IMPORTANT: 1 Ue corficate Holder i» an ADDITIONAL WSURED, the policyios) uate andorsed_W SUBROGATION IS WAIVED, Subjects the terms and conditions ofthe policy, certain policies may require an endorsement. A statement on this certificate dows not confer nares the certificate holder in leu of such endorsements). PRODUCER jane” Jennifer Swenson Leavitt Group of Spanish Fork. tne Sin, 801.798.7343 x20 —| [AE 866-306-4816 | Insurance & Surety Bonds Abbas; Jenni fer-swenson@leavitt.com P.O, 80x 757, 199 North Main usita ertane crear re Spanish Fork, UT 84660 [neuina: Cincinnati Tasurance: Coapany——|1069 ‘wsoneo Jack Daniels Construction, Inc. "| ngunere: Workers Comp Fund of Utah [10033 PO Box 842639 INSURER eae Hildale, UT 84784 INSURER D: Pee ieee zed ‘een COVERAGES ‘GERTICATE NUMBER: 0572013 —"T/ 20 TSO CERMET TET EPO UateD LOTTE REA EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN RECUCED Sr PAD GLAM [Se “TYPE OF mSURANCE aE POUGY NUMBER. ERENT [gerry | ae ama Game 510972043 0110172014 | can oSsoaence 3] comencn cenega usury cuamsamane [X } ocoun MED EXP (Any one parson) atte x ‘rentona abv uny| cl |cocmanconane GEN AGRE RES meoDucTs comm 6 | [X]roucr]X] 22% [Ivo [AVTowoeILEURFY RR 8515772015 sora ees ’ | aw amo | Scoe YAY span |S a [ |Mpoeeo (~) scvconeo | ‘BODILY NIRV Per wear F X]rmecorvros [XC Spregene® ee 5 ze LI Perea} X [nec TX Toomme |] WR 95012075 SOIT ome A [ Jeccrss ie cuaessce| tresrcoare cco | [nevewrens a oa OTMTADRA TRE TE fo eae tec scecicony {eT 000,0 2 | Seeerueanaes a] x Boia r Sosa U ners casio s 1580000 LISGIRFTON GF OPERATIONS nao EL DISEASE -POLICYLMT | 1,000, OF fenved/Leased tauipaant — SeRTADRS oTTaDTaT $250,000 Dede TIbTe 42508 | | Deductible $2500 a Bcheduted Equiprent {GESERITION OF OPERATIONS LGCATONS/VERELEN Aah AEORD TRE Romata Sau ¥ Bis HPAP S SSSR CERTIFICATE HOLDER ‘CANCELLATION TICENSif [SHOULD Ae OF THE ABOVE DESC NaED POLIS BE CANCELLED BEFORE ‘THE OxrraTION Dare THERROF, mOTCE WILDE DELIVERED N ‘ACCONDANCE wa THE POUT PROVIONS. RaTWOREED REPRERINTA TE CpuWh Starr Jenni fer Swenson/JESWEN ‘© 1988-2010 ACORD CORPORATION, All rights reserved. registered marks of ACORD ‘ACORD 26 (2010/06) ‘The ACORD name and logo a SePS! SERVICES LLC The State of Arizona Registrar of Contractors Emest Jessop PO BOX 7, THOREAU, NEW MEXICO 87323 PHONE NUMBER: 435.212.0011 ‘CANDIDATE 1D: XXK-AX-5584 008: a EXAM DATE: 04/10/2013 PORTIONNAME: AZ BME Business Managemest EXAM RESULT. PASS Congratulations! You have passed Ihe examination listed above. "Your passing scare is valid for up to two yoars from the date of the exem After passing all required examinations, submit this score feport In the Regisiter of Goniractars with your license application. License applications are avalable at www azrocgcy. Allrequiremonts of ARS.§ ‘must be met before a license willbe issued. The olowing tan reis four amination Tepie Questions #coneet ioe Register of Cortesors State 2 1 sora Register f Cotretirs Russ 0 + sors Pagistar of Contrada Wercnawap Sardar 3 Business Waoqement 2 Eneroemerts Laws and Recados 3 RESULT Tota 0 6 hereby certiy that | oid not give or recane (Printed Name) asoictance while taking ve exam, including he use of unauthorized notes. [further catty thet | wit ‘oatnue to abide by the PSI Security Agreement aged to Befara tang this exam Bate 20 Fropeasa Los Venus, EBI2t Bo. "Tos exaictior was dt vee ly PS Soins 3267PSI SERVICES LLC The State of Arizona Registrar of Contractors Emest Jessop PO BOX 67, THOREAU, NEW MEXICO 87323 PHONE NUMBER: 435-272-0011 CANDIDATE 1D: Xxx-xx-5584 boa: EXAM DATE: 04/10/2013, PORTION NAME: AZ A (KA) Gereral Engineering (Commercial) EXAM RESULT; PASS Congfatuistions! You have passed the examination lisied above. Your passing score i vali for up to two years fom the date of the exam. After passing all required examinations, sutmil this scora tepor to ihe Registra cf ‘Contractors with your ieonse application. License applications are avallable at www. azrociaov, Allrequuemerts of ARS § 32-1122 must be met belore a lcense will be issued Topic # Questions A Cones ‘Sore and Sopte Systems o : Wale Pog e 5 Excavson, Compaston, and Grading 4 Sates © Se Gaver a2 Trai Cant 3 Elacal Teresi Lines 3 1 Ep . hereby certify that I did net awe or receive: (Printed assistance while taking this exam. inchiding the use of unauthorized notes. | further cory that lil ‘coptinue to abide by the PSI Secuity Agrement agieed to betors Laking this exam Age Lie 4 Sianaire of Gudttying Paty oa ss examination was da 7 PRI Senvens, LLE™ 3210 Toph Vago NV die4. Business will operate as a le Numbe)_ lease include with your application a copy of the. of Organization, Articles of Incorporation, Armual Federal Tx Ientfcaton Naber (FIN) STATE OF ARIZONA REGISTRAR OF CONTRACT! ‘ORS APPLICATION FOR CONTRACTOR’! '$ LICENSE Tndividual applicable business formation documents and Test annual flings (te “Articles ‘Dasclosure Statement, or Partnership Agreement). 7 haaona Transaction Privilege Tax Number (TP) 7 Bases Aste ME _imeanim [oe She Ty 104s Ww uTy Aye #2. Hildalre ur BY28Y OT ae atest ee Stee As FO BOS Sey ae — ie Fe Bot 842634 Hldobe ul SUEY 5 Pine Habe ia ema ; BSS ~ SS -OCOT "pele lanjeleincG@ genet’ » o~ Ti. I would like to receive email notification 12. Workers’ Compensation: Check the box Compensation Act. ‘© _ A. Applicant as secured a Resolution of Aut for payment of of the certificate or insurance statement. when that ® ‘C. Applicant may employ workers who elect Compensation Insurance and will mai 23.961(A). Please attach a: D. Applicant is self-employed and will Workers’ Compensation, Please attach By signing below, Malling Address lst {qualifying person who is an employee only, are ‘Workers’ Compensation benefits to its employs B Apalicant hes complied by insuring and Keeping insured Tor payment of sch cosmhecoS with ‘authorized by the director of insurance to write ‘961(A)Q). Please attach a copy of the certificate or eee ele records «notice in writing that i signed and dated pursuant 0 A.R S$ ‘copy of the employee's notice of relecti ‘not employ workers and there the affidavit of self-e T certify under penalty of perjui easesation Insurance requirement) indicated in question 13. Additions, fed in question 7 and the persons nam ray license is due for renewal. NO. “indicates bow the applicant will comply with the Arizona Workers’ sorization from the ees pursuant to ARS. Tadusirial Commission of Arizona to act as a self '§23-961(A)Q). Please attach a copy ‘an insurance cartier PW arkers” Compensation Insurance inthis state, pursuant to A.R-S. § 23- insurance statement. To reject the provisions ofthe statutes oF rules governing Workers! oi | Tore is exernpt from the statutes or rules governing ayment exemption. ry that che business listed on this application meets the Workers! ‘by signing below T acknowledge that the tivon the attached Personnel Information pages, except for any ‘ihe personnel for all other ROC license(s) of this applicant. Printed Nae arley Rayo Jessop if signed by an owner, partner, member, manager, Part 2: Cancellation of Existing ROC License(s) Upon Issuance of New License TT herchy mest the cancellation ofthe following iense(@) upon ssuanee of tis new ease Licenses will only be eancelled | ‘Signaure Tile President officer, or director of the licensed entity ROC License # Ticease Nae ROC Licesse# Ticense Name Prinicd NamePart 3: Personnel Information Ts Fist Name Test Name, Eonest oe ba oath TSS Tair hai a oD) [7 Seca ey Nob ES oa 8D Ti Retrial AS — ay Sie fo Be 87 H_ Pendarese. Gros Mer a a ~ a any Ti Have you ever received a citation for contracting without a license? Ifyes, when and where “Da Have you ever been on contractor's Tense tssued by Arizona or any other state? YES tyes, state license status __livense # license name license class, Sir inve any of ihe Ticenss sed in question 2 ever been suspended, revoked or otherwise disciplined? Ifyes, which license(s) what is/are the current license status(es) what was the cause of the discipline Fi. Have you filed a petition fr bakrupley protection within the last 7 years under your indvial name or 8 behalf of any business entity? Hes, tach copes ofthe petiin(), docket report(s),all schedules and statements including Schedules E Joie the discharge order(s), and conformed plans where applicable. TS Have you ever been convicted ofa felony or have a felony charge pending? YES yes. you are required to complete and submit the Criminal History Disclosure Packet which may be obtained From the Licorsing Department or on our website: [p/w ares gowl-Fonms tum, You at still required Fae cyES" ff convtion has been vacated pardoned, expunged dismissed appealed ited oo 1 designated or otherwise reduced or your chil rights have been restored. You wil be notified in wring by ad eset non the Criminal History review i completed Do not submit you application unt notified 26. Have you ever been convicted of @ misdemeanor? tyes, when what chi which court Ti Fins you ever been delinquent in payinent oF any of he folowing: state or federal income taxes, payroll ‘withholding, social security, unemployment or workers’ compensation? Ives, attach a detailed explanation and provide apayment schedule, f applicable and Certificate of Good ‘Standing from the Arizona Department of Revent. Teertify that Ihave reviewed the entire contents of this application and all statements, answers, qn this application, including all supplementary statements attached hereto, are true and aoctra aaa ae of any information on this application isa violation of the Arizona Criminal Code in Tied Chapter27, Tunderstand that pursuant to A.R.S. §§ 32-1154(A)(6)(20) & 32-1122(D) p is cause for denial of this application and cause for discipline of ROC licenses. acknowledge that Tam a Person named on this license for the purposes and duties of all Regist Iuluding, Dut not limited to, A.R-S. §§ 32-1122, 32-1139(B) & 32-1154. These purposes and duitsda cessing cit of or relating to agreements that were entered into, monies received, or work performed while fam named om arsine oe oor gerstand thal because A.RS, § 32-L158(A) establishes a two-year period for the filing of complaints these purposes and duties continue for up Co two years after I disassociate from this license, By Submission of this application, I consent to a eriminal ba Printed Name rate Ernest Millward JessopPart 4: Personnel Information (All Other Persons or Entities, Te Fst Name ‘widale Nims Tat Nae Semone 7 Socal Security Name Pease enclose a co7y) Adiess Tooet Address Gill Baek BO Ta RE Na Pa atl, OG OT SOK | Uae - Fecebon 7 ‘ver received citation for contracting without a license? 21. Have you Ifyes, when and where, ZB. Have you ever been on & contractor's license issued by Arizona ityes, sto). “viense satus Acta ieense@_ CTL = 29 51% icone name Exathuorce. | latent __ioense class _QS- =p 5: Have any of he TcensesTsted in question 2 ever been suspended, revoked or otierwise disciplined? ‘or any other state?” If yes, which license(s) _what is/are the current license status(es) what was the cause of the discipline Fa Have you Filed a petition for bankruptoy protection within the last 7 years under your Tndividualnameoron YES behalf of any buesiness entity? Iyer attach copies ofthe petiion(), docket report), all schedules ard statements including Schedules E and F, the discharge order(s), and confirmed plans where applicable. 75. Have you ever been convicted ofa felony or have a felony charge pending? Ives you are required to complete and submit the Criminal History Disclosure Parke! which may be obtained ‘fram the Licensing Department or on our website p/w. uzros.eavil- For Intl, You are still required Fo cvs a conviction has been vacated pardoned, expunged dismissed appealed ved! at 1 designated or otherwise reduced or your evi rights have been restored. You wil bt notified in writing by a ete oben the Criminal History review is completed Do not submit you application wal not ied. 726, Have you ever been convicted of a misdemeanor? YES Ifyes, when what charge TT. Have you ever been delinquent in payment of any of the following: state or 2rd tging, socal security, unemployment or workers? compensation? Ives, attach a detailed explanation and provide a payment schedule if applicable ‘and Certificate of Good Standing from the Arizona Department of Revere. which court ‘federal income taxes, payroll ‘YES Tcovify tat T have reviewed the entire contents ofthis application and all statements, NST, ‘and rey ta its sppeaton, including all supplementary statements attached hereto, are {rue an eect 3 falsification of any information on this application is 2 Title 13, Chapter 27. Tunderstand that pursuant to A.RS. §§ 3 A cause for denial of this application and cause for discipline of ROC Heenses. ig Tale informatie | JUN 0 4 2013 | 1 acknowledge that Tam » Person named on this license forthe purposes and duties ofall Regist hee sajading, Dat wot limited to, AILS. 6§ 32-1122, 32-1139(B) & 32-1154. These purposes and wey Ho ace cat of or relating to agreements that were entered into, monies received) oF work porte ts r arising out of OF Momctaed that because A.RS. § 32-115S(A) establishes a two-year period for the filing of ‘complaints, these purposes and duties continue for up to two years after T disassociate from this eens. By Submission of this appli consent to a eriminal background investigation pursuant to A.R.S. § 32-1122). Prsied Nome Date Thomas Merril Jessop Piease complete and attach the Personnel Information forms for/ A peoplé named on the license. phing Part 4; Personnel Information (All Other Persons oF Entities, Not Qualifying Part Ta Figg Name ‘Middle Nee Tast Name ran: Ra Tessoyo TE Denar License Sie TNumber lease enclone@ 20) Eig Namba Press wees ce) FH Hine jou ever Fecehed a citation for contracting without a license? tyes, when and where. h Have you ever been on a contractor's license issued by Arizo ityes,saie__ AZ. ticense status_ ACTIVE ticense #_ KOC 279%4GO7 R01 = Cenbom:Oficense class 8-1 a Trecases1sted in question 22 ever been suspended, revoked or otherwise disciplined? a or any other state? 725. Have any off Ifyes, which license(s) _ what isfare the current license status(es)____ Sa Fisveyou filed pestion fr bankrupioy proection within the last 7 years under» ‘behalf of any Duesiness entity? If yes atach copies ofthe peition(s), docket report) all schedules and statements including Schedules E and F, the discharge order(s), and confirmed plans wher re applicable. e-Hiave you ever been convicid ofa felony oF have felony charge pending? ‘oar individual name or 0” yes. you are required to complete and submit the Criminal History Dislonrs Pot which may be obtained Fe Pe consi Departmen or on our website: tp fse carne Forms i. You are still required from he Leen Per eton hasbeen vacated pardoned, exe, demised appddled Ines 1 ated or otherwise reduced or your iil rights have been restored. You wit notified in writing by inde oe Criminal istry review i competed, Do no submit you cppicaton wt notified 26, Have you ever been convicted of @ what charge which court Zi Fave you ever been dolinquent in payment of any ofthe following: sate or Federal income taxes, payroll 27, Have social security, unemployment or workers) compensation I/yes, atach a detailed explanation and provide a payment schedule, Yfapplicable and Certificate of ‘Good Standing from the Arizona Department of Revenue. Taanly that Thave reviewed the entire contents of this application and as Joante Jpplication, including all supplementary statements attached hereto, are Coe and accu ina aay information on this application is a violation of the Arizona Cm Codeli i over 27, Lunderstand that pursuant {0 A.RLS. §§ 32-1154(AYO)20) & 32-4 120) recuse for denial of this application and eause for discipline of ROC Nicenses. nana JUN 0-4 2013 2 J acknowledge that Lam a Person named on this license for the purposes and duties of all Re tnaleding, Dat not Kite to, A.R.S. §§ 32-1122, 32-1139(B) & 32-1154. These puree and difties i trising out of or relating to agreements that were entered into, monies ‘received, or work performed wh Ghisigense, Lunderstand that because A.R.S. § 32-1155(A) establishes a two yie period for the filing of complaints, these furposes and duties continue for up to two years after I disassociate from this license. ‘By Submission ofthis application, I consent to criminal background investigation pursuant to A.R.S. Printed Name ‘Signatre Parley Rayo Jessop 32-1120). Tica comple and atach the Personnel taformation formsGoyAll pete named on the Ticense. ooPENDING / NEW QUALIFYING PARTY APPLICATION Contractor Tack Dare! Comemuc-had lac cass Oy RECEIVED (0° Y- | Lick OF SOU _ eviewep ay Netaive Initial/Date NAME-AVATABIEY ue BANKRUPTCY TAXES Goopay poste? CANCELLATION RARBG ieee eceaeaceraa| | 20 DAY POSTING: ASSUMPTION 180) ce 1127 PERCENTAGE: eGADON QPRESIGN come: 4-10-(3 [ Somme Tp = 7 [Erperenc Cues Daca {7} raescimas | Nactivesraros Teape: Y-| Q~ Woskes" Comp} “Tsou ces Pits ID (Gon Waray [ear cto ‘BK Documeats | RBCovERY Pam CONSUMER BOND ScREENS | Adi Company, ‘Add Personnel to Owaars Eick ‘Add DOR to each peison ‘History Reports applcante Sear) “At Credential TF [aa SEN tak peso Nase “asign Rovner Ba Pat, Cony TLE washes P| at Bok ee 7 “lid Work Order for os PER credential VJ] Aad RIF bond, ifappleable | peta Nores ‘Alpi wal adress — | aad Panda pe V4 aa personnel Rey (emo At tine) Manage Bog. (0 Lat spose Bi l4-1Q ot a) ae 12 =eNOTICE: FALSIFICATION OF ANY INFORMATION ON THIS APPLICATION IS A FELONY AND IMMEDIATE CAUSE FOR DENIAL. OF APPLICATION ONCE DISCOVERED PURSUANT TO AR.S. §32-1154,A. AND §32-1154.A.20 CONTRACTOR'S FINANCIAL STATEMENT FILL IN SUBMITTED BY: L2mate ‘An Individual ADDRESS. lobe LTS ___APatnership 7A Coxporation A Limited Liability Company Condon alse ofbusness tad wi SES 1. case @Onhand © Ehewhee 2 Nacsweete (Dewan ITaRT © due aters0 says (© Past due 3. Accounts receivable ftom completed contracts, exclusive of claims not spproved for payment 4. Sums earned on uncompleted contracts, as shown by Engineer's or Archive's estimate (2) Amount receivable after deducting retainer (b) Retainer to dae, due upon competion of contracts 5. Accounts receivable from sources other than constuetion contracts 6 Deposits forbids or other guarantees 7. Interest accrue on loans, secuttes ee 8 Real estate (2) Used for business purposes $ 8 s s 8 s (&) Not used for business purposes: 5 9. Stocks and bonds (2) Listed — present market value 8 {b), Unlisted ~ present value s 10, Materials instock ot (a) Fé urcorpteed conracts (aazeat vale) $ included in (8) Other materials (present value) 8 11, Bauipinent, book vale” | 8 12, Furniture and fixtures, book valve 5 8 1h Oherassets - ae LiaeiLimes 11 Now yao“) "(Tonge s (6) Tobanks or exc cocks $ (©) Tooter foreqipment blignions ——§ (6) Tootaseachsvee!eqpmentoignens 3 2. Accounts poyable:— (@) Not ps due s © Po aue 5 +3. Real estate encumbrances s 4 Ofte liblies $ 5. Reserves 5 6 Capi sick pid up: (@) Common $ © common 5 (©) Peed 3 Prefered $ 7 Supluecrwerny “ames $name § 1. theundersgned herehy verty under penalty of perf ja al the informgrion contained herein f tue tomy om knowlege, Faxlay 2 Seren, * tiainmedips PO “aad Berar Feesuchg ont Subst and wont ee esis, 31% yor May 13 Notary Public My Commision Expt State of County of RCL2IO1 11124:44 PM Jack Daniel's Construction, Inc oszan3 Profit & Loss ‘Accrual Basis January 4 through May 22, 2013, an 4 = May 22,13 Ordinary income/Expense Income Revenue ___3.421,47869 Total income: 3421,478 69 Cost of Goods Sold ‘Materials Purchased. 1,847, 928.32 Payroll ‘29727276 Payroll Taxes 15,244.60 Concrete Pumping & Cutting 4348.39 Costs for fuel 187,966.28 Engineering, Plans & inspection 3,806.7 Insurance Costs 108,423.56 Jobsite Costs ‘91,006.93 Lease & Rent Expense 234.26041 Lodging & Travel 70.783.65, Meals. 24.348 54 Repairs and Maintenance €0.226.35 ‘Subcontractor Costs 63,880.19 ‘Taxes, Licenses & Permits 3,722.69 ‘Transportation Costs 415.501 20 ‘Worker's Componsation Insurance 9201.72 Totai Coss: ___2,906,241.58 Gross Profit 817,297.41 Exponse Business Licenses 4.01000 ‘Computer and Internet Expenses 8185.54 Contract Services £800.00 ‘Dues & Subscriptions 9.35845 Financial Services 3,704.37 Office & Yard Lease 10.474.00 Office Moats 39.46 Office Payrott 7,335.48 Office Payroll Taxes “764.24 Office Repairs & Maintonsnoe Office Supplies Office To Office Utiities Postage and Shipping Professional Services 2 Total Expense 108,435.68 ‘Net Ordinary Income 408,803.43 ‘Other Income/Expense ‘Other Expense Interest Expense 8,920.08 Penalties (Fines & Tickets) ite 1689.00 Total Other Expense 8.60008 Not Other Income _____-9.808.08 Net income Page +py bd badd yoo yee VI Peete eee Jack Daniel's Construction, Inc. FINANCIAL STATEMENTS AND ACCOUNTANT'S REVIEW REPORT Year Ended December 31, 2012LeRoy S. Jeffs Certified Public Accountant INDEPENDENT ACCOUNTANT'S REVIEW REPORT ‘To Management ‘Jack Daniel’s Construction, Ine. Hildale, Utah L have reviewed the uecompanying balance sheet of Jack Daniel's Construction Inc. (an S corporation) as of December 31, 2012, and the related statements of income, stockholder’s equi: cad cash flows for the year then ended. A review includes primarily applying analytical procedures fo management's financial data and making inquiries of Company management. A review is substantially less in scope than an audit, the objective of which is the expression of an opinion regarding the financial statements as a whole, Accordingly, I do not express such an opinion. The 2011 financial statements of Jack Daniel’s Construction, Ine. were reviewed by another accountant, Gehose report dated April 25, 2012, stated that based on her procedures, she is not aware of any Inaterial modifications that should be made to those financial statements in order for them to be in ‘conformity with accounting principles generally accepted in the United States of America. Management is responsible for the preparation and fair presentation of the financial statements in accordance with accounting principles generally accepted in the United States of America and for designing, implementing, and maintaining internal control relevant to the preparation and fair presentation of the financial statements. My responsibility is to conduct the review in accordance with Statements on Standards for ‘Accounting and Review Services issued by the American Institute of Certified Publie Accountants. ‘Those standards require me to perform procedures to obtain limited assurance that there are no material modifications that should be made to the financial statements. I believe that the results of my procedures provide a reasonable basis for my report. Based on my review, I am not aware of any material modifications that should be made to the 2012 financial statements in order for them to be in conformity with accounting principles generally accepted in the United States of America. ‘The supplementary information contained in Schedule { is presented for purposes of additional analysis and is not a required part of the basic financial statements. Such information has been Subjected to the inquiry and analytical procedures applied in the review of the basic financial Statements, and Lam aot aware of any material modifications that should be made thereto. Z April 23, 2013 1020 West Utah Avenue P.O. Box 841938 Hildale, Utah 84784-1938 (918) 344-2198Jack Daniel's Construction, Inc. r Balance Sheet is ASSETS 2012 r Current assets: a Cash and cash equivalents $ 340,158 Certificates of deposit 50,062 Accounts receivable 1,935,466 - Employee receivables - - Costs and estimated earnings in excess of billings 35,401 - Total current assets 2,361,087 Fixed assets: - Construction equipment 976,398 ‘Transportation equipment 71,733 iat Office furniture and equipment 8,757 ae Total fixed assets 1,056,888 ee Less accumulated depreciation 301,532 6 Net fixed assets 955,356 6 Other assets: zi Deposits : Total assets $3,316,443, iJack Daniel's Construction, Inc. Balance Sheets (Continued) LL sTOCKHOLDER'S EQUITY Current liabilities: ‘Accounts payable Accrued expenses Lines of credit Notes and contracts payable, current portion Billings in excess of costs and estimated earnings Total current liabilities Notes and contracts payable, net of current portion ‘Total tiabilities Stockholder's equity: ‘Common stock, $0,001 par; authorized 1,000 shares; issued and outstanding 1,000 shares ‘Additional paid-in capital Retained earnings Total Stockholder's equity Total liabilities and Stockholder's equity 2012 $ 1,437,033 105,086 104,991, 213,490 1,860,600 510.235, 2,371,335 151,263 793,844 948,108 $__ 3,316,443 ‘Se accompanving noes and accouneaks por,Jack Daniel's Construction, Inc. Statement of Income December 31, is 2012 ‘Construction revenue $ 10,843,088 i Costs of revenue 10,145,332 - Gross profit 697,156 3 Operating expenses 330,859 : Net operating income 366,897 ‘Other income and (expenses): - Interest income 62 r Penalties 02) = Interest expense (56,301) ee Total other income and (expenses) (56,541) a Net income $_ 310,356 z See accompanying aotes and acconnFane 29". un 94203 oh ia CENSING :Jack Daniel's Construction, Inc. ‘Statement of Cash Flow: Cash flows from operating activities: Net income Adjustment to reconcile net income to net Cash provided by operating activities: Depreciation and amortization (Increase) decrease in assets: Certificates of deposit ‘Accounts receivable Employee receivables Costs and estimated earnings in excess of billings Deposits Increase (decrease) in abilities: Accounts payable Acerued expenses Billings in excess of costs and estimated earnings ‘Net cash provided by operating activities Cash flows from investing activities: Purchase of equipment Net cash (used) by investing activities Cash flows from financing activities: Principal payments on long-term debt ‘Net cash (used) by financing activities Net increase (decrease) in cash and cash equivalents Cash and cash equivalents at beginning of year Cash and cash equivalents at end of year ‘See accompeyng notes and acsountants repr. December 31, 2012 $ 310,356 93,019 (50,062) 6,837) 1,690 (16,541) 2,500 290,138 (106,619) (57,309) 461,335 (95,910) (95,910) 480,488) 180, 184,937 __ssiay $340,458 JUN 94 2013 2) Th jensenJack Daniel's Construction, Inc. Statement of Cash Flow (Continued) Year Ended December 31, 2012 Additional eash flow information: ‘Cash paid during the year for: Interest $3 55,986 Noneash investing and financing activities Purchase of equipment through assumption of long-term debt S 312,845 Purchase of equipment through assumption of current debt s 6,300 See accompanying notes and accountants repo Office furniture and equipment TO Yeare JUN 9-4 2013 ot .Jack Daniel's Construction, Inc Balance Sheet ‘As of May 22, 2013 ASSETS ‘Current Assets CChecking/Savings ‘Cashin Bank ARIAP Joint Checks ayments Pending Total Checking/Savings ‘Accounts Receivable ‘Accounts Receivable ‘Total Accounts Recelvable Other Current Assets ‘SBSU- CD Total Other Curront Assets Total Current Assets Fixed Assets ‘Construction Equipment ‘Transportation Equipment Office Furniture and Equipment Less Accumulated Depreciation Total Fixed Assets ‘TOTAL ASSETS LIABILITIES & EQUITY ‘Liabilities Current Liabilities “Accounts Payable ‘Accounts Payable Total Accounts Payable Credit Cards ‘Office CC Total Creat Cards Other Current Liabilities ‘Accrued Interest Payable Loan Payable Payroll Liabilities SBSU - Credit Lino 'SBSU -Traller Short-Term loan Current Portion of LT Debt Total Other Current Liabilities ‘Total Current Liabilities Long Term Liabilities 'SBSU - Power Trowel Phaze-Tex 7,500/Mo TGF Eq Fin 1,549.69/Mo CNH Capital 2,562.36/Mo ‘Cat Fin 289C Loader 1,754.40Mo GE Capital 2856 53/M0 Royal Bank 1,243.00/M0 SBSU -07 Kenworth 1,373.68/Mo Foundation Software 812.29/Mo ‘Less Current Portion LT Debt ‘Total Long Term Liabilities Total Liabilities May 22,13 169521.15 45.308 12 4,799.97 213,105.30, 2,188,379.08 2,188,379.00 90,062.32 150,082.32 2,421,546.71 991,000.44 157,763.39 30,172.32 101,532.31 1,058,296.64 3479,840.56 1:314,886 00, 1.314,086.00 77,008.46 316.28 29,000.00 87,021 53 100,000.00 ‘600.00 99,681.23 31562801 1.628,289.55 26,850.00 282:351.73, 7.38046 42,659.35 34,600.31 35.917 67 4724073 140,950.00 an70271 98,691.25 49726171 2,126,541.26 Paget444 PM ost Accrual Basis Jack Daniel's Construction, Inc Balance Sheet ‘As of May 22, 2013 Equity ‘Capital Stock. Addi Paid.in Capital Retained Earnings ‘Shareholder Distributions Netincome Total Equity TOTAL LIABILITIES & EQUITY May 22,13 4.90 151,268.00 793,843.94 9,000.00, 309,104.35, 1,988,308.28 3.470,843.55 Poge 2Jack Daniel's Construction, Inc. Notes to Financial Statement NOTE.1- BUSINESS asin r Jack Danis Consructon, ie: (he Company) is engage in const consaion the southem United eats work is performed under fixed-price contracts, cos-plus-ve OO and on an hourly basis. ec oranted to customers in the residential commercial and industria con Nek industry. Consequent!, sets cays ail to eolet the amounts due fom customers is fered) ‘economic fluctuations in the ae mtn industry, ‘The Company follows the practice of filing stautory Hens O° all construction projects a eebleme ar antipated. The Fens serve a oltre fr eonract rehab LICH f Management's Review, Management has evaluated subsequent events through Apri 23,2013, the date on ‘which the financial statements ‘were available to be issued. u wivale ach and cash equivalents include cash in barks and all highly liquid investments with a maturity of three ‘months ot less. Accounts: bt ‘As revenue is billed, asounts reeivable are recorded and are presented in the balance sheet net of the owence for doubtl accounts. Accounts rocsivable are writen off whet! they axe determined to be scotleatible. Subsequent recoveries of amounts previously written off ae credited directly to earnings. The ‘Company believes io allowance for doubtful accounts is necessary st December 31, 2012 Fined Assets and Depreciation Fixed assets are stated on the basis of cost, Maintenance, repairs, minor renewals and betterments which do not cn ihe woeful life of equipment are charged to expense as incurred. Major renewals and betterments are Contalied. ‘The cost of equipment sold or otherwise disposed and the related accumulated depreciation is cared om the azcoants, and any gains or losses arising ffom sale oF isposal are included in income. Depreciation is computed using the straight-line method over the folowing ‘estimated useful lives: Construction equipment 5-10 Years, “Transportation equipment 10 Years Office furniture and equipment 5-10 YearsJack Daniel's Construction, Inc. Notes to Financial Statement NOTE2- Sur INTING POLI Management Estimates ‘The preparation of financial statements in conformity with generally accepted accounting principles requires ‘management to make estimates and assumptions that affect certain reported amounts and disclosures. Actual results could differ from those estimates. Material estimates specifically relate to the estimated cost to complete work in progress and the resulting income expected. ‘Revenue and Cost Recognition Revenues from fixed-price construction contracts are recognized on the percentage-of-completion method, measured by the percentage of cost incurred to date to estimated total cost for each contract. This method is ‘used because management considers total cost to be the best available measure of progress on these contracts, Revenues from cost-plus-fee contracts are recognized on the basis of costs incurred during the period plus the fee earned. Revenues from work performed on an hourly basis are recognized during the period performed. Contract costs include all direct material, subcontract and direct labor costs. They also include an allocation of costs related to contract performance, such as indirect labor, supplies, tools, repairs, and depreciation. Selling, ‘general and administrative costs are charged to expense as incurred. Provisions for estimated losses on ‘uncompleted contracts are made in the period in which such losses are determined. Changes in job performance, job conditions, and estimated profitability may result in revisions to costs and income and are recognized in the period in which the revisions are determined, The asset, "Costs and estimated carmings in excess of billing,” represents revenues recognized in excess of amounts billed. The liability, "Billings in excess of costs and estimated earnings,” represents billings in excess of revenues recognized. ‘Advertising Costs ‘The Company expenses all advertising costs when incurred. The Company incurred no advertising costs during, 2012 ‘Taxes ‘The Company has elected by consent of its shareholder to be taxed under the provisions of Subchapter S of the Intemal Revenue Code. Under those provisions, the Company does not generally pay corporate income taxes on its taxable income, but passes through its taxable income to its stockholder. ‘Sales Taxes ‘Any sales tax charged a customer is included in construction revenue and sales tax revenue, included in costs of 4 ae i A I gun 94 2013 4 ime aWork Experience Record NOTICE: FALSIFICATION OF ANY INFORMATION ON THIS: [APPLICATION IS A FELONY AND MAY \ Soe se UAUSE FOR DENIAL OF IBE APPLICATION ONCE DISCOVERED. RS. 85325 LISLA.G AND 32-1154.4.20 \ 2uslfving Party Name Garegt ————STrnttegs 2 Dae of Binh [es G Near Sx Roa mployer’s Name 7 S.Employer's Tye Abt repute sad _ ticenseNumber _fz- ROC 279902 rmployer's Malling Address A639 Hilde y feaatar Supervisor's Name Tian Barber! ‘er Na hair OT Rome PASO, AE) ommend aca Renal, fused 8 AEs wok, eset om pach 2009 te Mg — QarB_ tour vers Q__ Mons {erage hours worked per week SD_ 10 Number of people you supervised Lx ieee ‘Check all jb postions you held for this employer: Job Title ‘Mouths Years Job Title Months Years Laborer Project Manager 3 Apprentice T= 1 Satfemplayed ‘ Joumeyman TTT G_ Licensed AZ Contractor eae Foreman D—_Outof State Contractor i - Superintendent L TET Other ‘Approximate numberof pojects "Residential __— D = __13. Average size range ofthese pojests: From = shed for disemployer fee epee ce a aus Describe your major duties Emest Jessop ‘Gala Pny Prd Rae VERIFICATION STATEMENT ‘To be complgted by the verifier aftr the above named qualifying party has completed questions | ~ 5. relationship to slwas (check al tht apply) Teas of ai Pare Employer q Jourmeyman — ]_ Foreman (1 Superintendent HContractor Employee Client (E) Business Associate Ether: License #: TX rifier’s residential address: /OQ§" 49 2 i _ Ur BY?BY-2639 ‘Address Gir ser State Zip one: 2ES= GSS-0007. Fax No: _ £SS-G@SS- 0008 E-mit: _jockdanth ine @aaay comm oe reer one work experiance forthe tne period oulned above. he undersigned hereby verify ander peaahy sei ata oe noraon contained herein is tre to the best fry knowledge and belief, Fokns BLT Files Bred Name : Date bscved nd svom to before mes 22. devo May 1 tary Public fase fuctey “My Commission Expires: "y eee Beet ef ee Eee Ep eer ‘L-20081 12/12 TSRCATBRT SWOT BTOME METS = Fi fNOTICE: FALSIFICATION OF ANY INFORMATION ON THIS APPLICATION IS A FELONY AND IMMEDIATE CAUSE FOR DENIAL OF APPLICATION ONCE DISCOVERED PURSUANT TO A.R:S. §32-1154,A.6 AND §32-1154..20 Project Information One project per page 1. Qualifying Pary Name ot , 2. Progeny Omer Name 7 thang Des ri Pee bac Roce eerste 3. Property Address nay Tan BU Chile Ea he i 4. Mailing Address GE different from property address) 5, Job Description 6, Date ofjob PSE 7 a Fas aT Tae 7, size bom Tiny A Adal ee wn 1 Aysecicn ‘VERIFICATION STATEMENT “To be completed by the verifier after the sbove named qualifying party has completed the proj ty relationship to ic 2» {is/was (check all that apply): ‘Name of Qualifying Pariy 2 Project. «Property Home’ (Superintendent General Coney 1D SubContracior ‘Owner Owner ee NY Costus License ‘Verifier’s residential address: e Nee tone: Shey, ef] Fac E-mail ‘verify that [have direct knowledge ofthe project outlined above, I, the undersigned, hereby verify under penalty of perjury tha ll of the formation contained herein is true tothe best of my knowledge and belief. Rear 2 Soe” Same 7 ie ubseribed and swom totefore me this 2/3 dey of May M43 gs es et meee eae ary Publ My Commission Expires: 1g / 2017. Sate ot “pd County of: “Was kengFon, AC-4-20081 1112NOTICE: FALSIFICATION OF ANY INFORMATION ON THIS APPLICATION IS A FELONY AND IMMEDIATE CAUSE ROK MENIAL. OF APPLICATION ONCE DISCOVERED PURSUANT TO A.RS. §32:1154.8.6 AND §32-11548.20 Project Information ‘One project per page 1 utnigrinrnine Finest Tegege 2. Property Owner Name Heber Che Qe St Whew 3. Property Address Sees aes eben a : 74 Z 4. Mailing Address Taig haa (it diferent from propery address) Z oe Tar co Tp 5. Job Description PEs RE REECE eee 6. Date ofjob Fel [7a _~ Diode (776 “Ta ont) 1. ste Qiks cm Ls mall eS ‘VERIFICATION STATEMENT ‘To be completed by the verifier after the above named qualifying party has completed the project information, ty relationship to Ervtest Wt. ~Tess: is/was (check all that apply) ~SNanc of Qaliving Pa 1 Project Property Home) Superintendent (9 General Contractor 1 Sub-Contractor Over Owner License # License #: Verifier's residential address: _ S50 C2: _/710, ZL , SEGe. Tres ed ar i hone: 35-79-6235. Fax E-mail: verify that Ihave direct knowledge of the project outlined above. I, the undersigned, hereby verify under penalty of pexjuy that all ofthe formation contained herein is true tothe best of my knowledge and belief. : es a Dg S213 ere None a sh scribed and swom to before me this_ LL day of_ ey 013 ways) ¢ i au 94203 ingen} LICE 3 My Comm. Expes Jan 8 2017 RCL-20081 11/12-ALSIFICATION OF ANY INFORMATION ON THIS APPLICATION IS A FELONY AND IMMEDIATE CAUSE FOR NOTICE: F DENIAL OF APPLICATION ONCE DISCOVERED PURSUANT TO A.RS, §32-L154.4.6 AND §32:1154.4.20 Project Information (One project per page Qualifying Pary Name Ecnest pil “Jesse 2. Property Owner Name C4 Sedan Breen Rt ~ falesede Dr 4. ppm nts Pest ek = se i Sedona AZ Se i: 02 Boudrun 4. Maing Ades bat (tainee sem pepe ate) | 5 . Le = i 5. sobDeeipion 7, a. i 6. Dae ofjob Wee fgg Fonbe LOG ran Gees) Tema 7. Size 8. cot F/O silln ‘VERIFICATION STATEMENT ‘To be completed by the verifier after the above named qualifying party has completed the project information fy relationship to_ Exries# _/7?. Je ssoyo ‘was (check all that apply): ‘Name of Qualifying Party 2 Project Property Home C. Superntendent 2 General Conracor 2 Sub-Contractor ‘Owner Owner License # Verifier’ residential address: _ 580 Co Prohave, Tie hone: 425-29 -CO22 Fax: E-mail verity that {have disect knowledge ofthe project outlined above. I, the undersigned, hereby verify under penalty of perjury that all ofthe formation contained herein is true tothe best of my knowledge and belief. Sozette (erlar) sah Geer [Iwao Name tsi and swomto teem this 22% savor May 2012 2 ‘otary Pubic 7 My Conimission Expires: _t/ ¢ State of County of. RCL-2008H {1/12NOTICE: FALSIFICATION OF ANY INFORMATION ON THIS APPLICATION IS & FELONY AND IMMEDIATE CAUSE FOR TAINIAL OF APPLICATION ONCE DISCOVERED PURSUANT TO A.RS. §32-LIS48.6 AND §32:1158.4.20 Project Information One project per page 1. Quins Pay Nene Eenest IM Sess? 2. Property Owner Name (~ af Sed A Height Subdinivion La 3, Property Address ca do ng S20. tr Soe Tr une 3 «Mtg ning —L2 Boadesanee Md _ B37 (i citferene rom propery adress) Sedona —___Ag $4485 — Tae i Job Description : ; a dk ae Casa ts £3 a peer ej Fax Eval verify that have direct knowledge ofthe project outlined above, [, the undersigned, hereby verity under penalty of perjury that all ofthe formation contained herein i true to the best of my knowledge and belief. : —\ arate Fie sbseribed and swom to before methis_2/ 2# “dey or May 2013 r= c 1, rh jay hails 7A WY My Commission Expires: State of: County of; RC-L-20081 11712‘Copy Dor EmployerAriz, Corp. Comm. -- Corporations Division Page 1 of 3 Arizona Corporation Commission 06/04/2013 State of Arizona Public Access System. 8:23 AM. Jump To... Annual Reports Scant uments E-FILE Ani Annual Report Online << Click Here: j FORMS For Annual Reports To Be Printed And Mailed << Click Here Corporate Inquiry {Fite Number: F-1771177-2 Check Corporate Status (Corp. Name: JACK DANIEL'S CONSTRUCTION, INC. Domestic Address 2829 MCGILL BLVD. SAN ANGELO, TX 76905 Foreign Address 1010 E JEFFERSON PHOENIX, AZ 85034 Statutory Agent Information ‘Agent Name: NATIONAL CONTRACTOR SERVICES C ‘Agent Mailing/Physical Address: 1010 E JEFFERSON ST PHOENIX, AZ 85034 ‘Agent Status: APPOINTED 06/25/2012 ‘Agent Last Updated: 08/09/2012 Additional Corporate Information [Corporation Type: BUSINESS [Business Type: [Incorporation Date: 06/25/2012 [Corporate Life Period: PERPE: Domicile: TEXAS [County: MARICOPA ! I | http://starpas.azcc.gov/scripts/cgiip.exe/WService=wsbroker! /names-detail.p?name-id=F 17... 6/4/2013Ariz. Corp. Comm. -- Corporations Division |Approval Date: 06/27/2012 Officer Information rage «ole lor [PARLEY RAYO JESSOP PRESIDENT PO BOX 3947 ISAN ANGELO, TX 76902 pate of Taking Office: 06/25/2012 luast Updated: 06/27/2012 [THOMAS MERRILL JESSOP |VICB-PRESIDENT IPO BOX 61637 SAN ANGELO,TX 76906 IDate of Taking Office: 06/25/2012 [uast Updated: 06/27/2012 Director Information PARLEY RAYO JESSOP DIRECTOR pO BOX 3947 ISAN ANGELO, TX 76902 bate of Taking Office: 06/25/2012 [THOMAS MERRILL JESSOP [DIRECTOR IPO BOX 61637 ISAN ANGELO, TX 76906 Date of Taking Office: 06/25/2012 Last Updated: 06/27/2012 juast Updated: 06/27/2012 Annual Reports [Next Annual Report E-FILE An Anrival Report Online << Click Here IDue: 06/25/2013 FORMS For Annual Reports To Be Printed And Malled_<< Click Here J | No Annual Reports on File ack To Top Scanned Documents (Click on gray button to view document - will open ina new window) cnet Description Date Received 03935350_] APPLICATION FOR AUTHORITY lo6r25/2012 03975506_]|PUB OF APPL FOR AUTHORITY lov12012 Back To To! ‘© Corporate Name Search Instructions ‘* General Web Site Usage Instructions ¢ STARPAS Maip Menu ¢ ACC, Corporations Division Main Page ‘© Arizona Corporation Commission Home Page http://starpas.azec.gov/scripts/cgiip.exe/WService=wsbroker! /names-detail.p?name-id-F 17. ee 6/4/2013Ariz. Corp. Comm, -- Corporations Division Page 1 of 1 Arizona Corporation Commission State of Arizona Public Access System 8:23 AM 061042013 Corporate Status Inquiry [File Number: F-1771177-2 (Corp. Name: JACK DANIEL'S CONSTRUCTION, INC. This Corporation is in Good Standing hhis information is provided as a courtesy and does not constitute legally binding information Iregarding the status of the entity listed above. To obtain an official Certificate indicating that in good standing click on Print Certificate and follow printing instructions. To re- enerated Certificate of Good Standing click Reprint Certificate. hitp://starpas.azec.gov/scripts/egiip.exe/WService=wsbrokerl/ws179.p 6/4/2013Prom orice EX Thaw: Wasnitcrox Se: Sre.105 -tecsosomnice Pron AZ 850072812 awww, cosenrse St-212 Iarray AZROC (1877692976) a (G20) e285 ARIZONA REGISTRAR of CONTRACTORS ADDRESS CHANGE [Retum this (printed or typed) form with an original signature to the Phoenix office at: ‘P.O. Box 6688, Phoonix, AZ a atter two weeks, verify your address has been received and recorded by checking your company at our [s8005-s608. web site hitpv/www.azr0°.g0v. JARS. § 32-1122. B. requires applicants provide the “address or location of the place of business’ referred to in this form che Rusiness address. A place of business address cannot be a P.O. Box, PMB or mailbox store address. A separate] Irsailing address must also be listed if different from the place of business. Examples of malling addresses include but are ot imited to a P.O. Box, PMB of mailbox store address. lnote: You are responsible for maintaining a correct address with the agency. An incorrect mailing address of record Jou result in disciplinary action or even revocation of a license should you not receive legal notification of any agency \cotion. This mailing address will become your offical address of record and all Registrar of Contractors’ correspondence |will be sent to your new mailing address. Irhese changes will apply to Al licenses held by this company. Please initial in the box to indicate acknowledgement of this statement. Please note that an incomplete form will be returned, List all icense numbers, Jack Daniel's Construction, Inc. Date: 05/20/2013 License Numbers lersoo2 ie le ke le le le Company Nami Malling Address cars ra ln om Fe PO Box 61637 San Angelo Tx 76008 Fara ie Fame be PO Box 642639 Hildale UT e4784-2690_| 2829 McGill Blvd Bas Actos 1045 West Utah Ave Sto#2 Email Address, By completing this Address Change form you acknowledge your understanding that this mailing address change applies toall licenses held by this company. You also acknowledge your understanding that all correspondence from the Registrar for any license held by your company wil be sent to the Malling Address provided. . x ‘ i 05/20/2013 fly dae —— ‘Member or Printed Name of Signer tT JUN 0 4 20f8te Corporate Officer {Employee QPs may not sign) Faxed for not i 4 ‘acceptable : UENINS i aabatachabahbscuveare ReLaoa 1312 Visit our webeit: waw.azr0c.gov ‘Adaress Change Page 1 oftJune 06, 2013 \ Jack Daniel's Construction Inc PO Box 842639 Hildale, UT 84784-2639 Re: Pending Application A.285604-C has been received ‘The processing of your application cannot be continued until the following addi provided. It appears that #22 for Emest Jeesop was answered incorrectly. Please revise. The above requested documentation or a written request for an extension must be received by this office within thirty (30) days of the date of this notice to avoid the application being returned. Sincerely, v Natalie Garrisan Natalie Garrison, Customer Service Representative 1700 W. Washington St. Ste. 105 Phoenix, AZ 85007-2812 Phone: (602) 542-1525. Fax: (602) 542-7852 ist our webste at: ww azzoc gov ReL20e 43LICENSE BOND THIS BOND MUST BE ON FILE WITH THE ARIZONA REGISTRAR OF CONTRACTORS STATE OF ARIZONA REGISTRAR OF CONTRACTORS BOND NO:_ns6150930 That Jack Dania’s Construction, ine. as the principal, and ALJ insurance Company (Surety) 2 corporation, duly authorized and licensed to transact surety business in the State of Arizona, ate held and firmly bound unto the Slate of Arizona for the benefit of those persons described in A.R.S. §32-1152, as amended, in the penal sum set forth for the lassification of license described: LIGENSE CLASSIFICATION PENAL SUM JENERAL ENGINEER 5,000 A Seve gop cases ine bal has spalied tothe Registrar of Contractors ofthe State of Arizona for a icense to conduct the business of contracting Under the above-described classifications and submits this bond to comply with the provisions of A.R.S. §32-1152, as amenuoa. atich are incorporated herein as though fully get forth Liabilty under this bond is Limited to the penal sum for each classification of work performed by tho principal, Liability under each lassiication shall be determined strictly in accordance withthe provisions of ARS, 832-1 152, as amended, which are mneorporeted herein as though fully set forth. pen making payment fo claimant against the bond, the Surety shall immediately give written notice to the Principal and the Registrar of Contractors of the date and amount of payment. Rie amount of this bond is besed on the representation ofthe Principal ofthe anticipated ennual gross volume of work pursuant to Ruie R4-9-112. This bond becomes effective on ard day of June. SIGNED, SEALED AND DATED _3rd day of _June. 7 LICENSING A NA rint OF Type Name of Atforney-In-Fact ‘Subscribed and sworn to before me this __3rd day of, THE ORIGINAL BOND MUST BE SIGNED BY THE PRINCIPAL, ATTORNEY-IN-FACT AND THE NOTARY PUBLIC AND BE FILED WITH THE REGISTRAR OF CONTRACTORS AT: 3838 N. CENTRAL AVE., STE 400, PHOENIX, AZ 85012-1946, TO COMPLY WITH A.R.S. §32-1152