Blackburn Creek Community Development District
12051 Corporate Boulevard, Orlando, FL 32817
Phone 407-723-5900; Fax 407-723-5901
www.blackburncreekcdd.com

The meeting of the Board of Supervisors for the Blackburn Creek Community Development District will be held Wednesday, December 11, 2019 at 12:15 p.m. at the 5800 Lakewood Ranch Blvd, Sarasota, FL 34240. The following is the agenda for this meeting.

Call in number: 1-844-621-3956 (New) Passcode: 790 562 990 # (New)
 BOARD OF SUPERVISORS’ MEETING AGENDA

Organizational Matters
Call to Order
Roll Call
Public Comment Period [for any members of the public desiring to speak on any proposition before the Board]

General Business Matters

Consideration of the Minutes of the November 13, 2019 Board of Supervisors’ Meeting
Ratification of Payment Authorizations 99 -- 101
Ratification of Requisitions 2018-115 – 2018-116
Ratification of Requisitions 2019-53 -- 2019-58
Review of District Financial Statements

Other Business
Staff Reports
District Counsel
District Engineer
District Manager
Audience Comments
Supervisors Requests

Adjournment 

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Consideration of the Minutes of the November 13, 2019 Board of Supervisors’ Meeting

MINUTES OF MEETING

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT BOARD OF SUPERVISORS MEETING MINUTES
Wednesday, November 13, 2019 5800 Lakewood Ranch Blvd.
Sarasota, FL 34240
12:15 P.M.

Board Members Present:

Pete Williams	Chairperson		
Dale Weidemiller	Vice Chairperson		
Kevin Johnson	Assistant Secretary		
John Blakley	Assistant Secretary		
Jerald Dell	Assistant Secretary		
Also present:			
Vivian Carvalho	District Manager- PFM Group Consulting, LLC	
Venessa Ripoll	PFM Group Consulting, LLC		
Bill Conerly	District Engineer- Kimley-Horn	(via phone)	
Jim Schier	Neal Communities		

FIRST ORDER OF BUSINESS		Organizational Matters Call to Order and Roll Call
Ms. Carvalho called to order at 12:21 p.m. the meeting of the Board of Supervisors of the Blackburn Creek Community Development District and proceeded with roll call. The persons in attendance are as outlined above.

Public Comment Period

There were no members of the public present at this time.

SECOND ORDER OF BUSINESS	General Business Matters

Consideration of the Minutes of the October 9, 2019 Board of Supervisors Meeting

The Board reviewed the Minutes of the October 9, 2019 Board of Supervisors Meeting.

On MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board approved the October 9, 2019 Board of Supervisors Meeting.

Consideration of Resolution 2020- 02, Annual Appropriations and Adopting the Revised Budget for Fiscal Year 2019

Ms. Carvalho explained 60 days within the beginning of the Fiscal Year the Board must adopt a revised budget if there are any changes within the budget which are a difference of 10% or $10,000.00.

The Board reviewed the revised budget. Mr. Williams stated that it is a governmental accounting function that is required and it would be noted in the Audit. The Board cannot increase it above the District’s sources of revenue but the Board can re-appropriate dollars in between categories to balance the budget.

On MOTION by Mr. Williams, seconded by Mr. Johnson, with all in favor, the Board approved Resolution 2020-02, Annual Appropriations and Adopting the Revised Budget for Fiscal Year 2019.

Ratification	of	Payment Authorizations 94-98

The Board reviewed Payment Authorizations 94-98.

On MOTION by Mr. Weidemiller, seconded by Mr. Williams, with all in favor, the Board Ratified Payment Authorizations 94-98.

Ratification of Requisitions 2018- 113 – 2018-114

The Board reviewed Requisitions 2018-113 – 2018-114.

On MOTION by Mr. Williams, seconded by Mr. Weidemiller, with all in favor, the Board Ratified Requisitions 2018-113 – 2018-114.

Ratification of Requisitions 2019- 36 – 2019-52

The Board reviewed Requisitions 2019-36 – 2019-52.

On MOTION by Mr. Weidemiller, seconded by Mr. Williams, with all in favor, the Board Ratified Requisitions 2019-36 – 2019-52.

Review	of	District	Financial Statements

The Board reviewed the District Financial Statements through October 31, 2019 the first month of the new fiscal Year.

Mr. Williams asked if Ms. Carvalho anticipates that they will reissue the financial statements if the Accountant makes any adjustments that would impact those statements from year end. Ms. Carvalho responded that Ms. Lane, the District Accountant, tries to take in consideration all the contractual obligations and or invoices that have not come in. If there is a reclassification and the Accountant has to adjust it she will adjust it and bring it back to the Board for review and acceptance at the next Board Meeting.

On MOTION by Mr. Williams, seconded by Mr. Johnson, with all in favor, the Board accepted the District Financial Statements for October 31, 2019.

THIRD ORDER OF BUSINESS		Other Business Staff Reports
District Counsel – Not present

District Engineer – Mr. Conerly informed the Board that he has requisitions that are being processed that will be presented at the next meeting for ratification.

District Manager – Ms. Carvalho stated that the next meeting is scheduled for December 11, 2019 at 12:15 p.m.

FOURTH ORDER OF BUSINESS	Audience Comments and
Supervisors Requests

Mr. Blakley requested an ADA insurance update. Ms. Carvalho replied that the Board approved the agreement at the last meeting. The proposal is a backup to that agreement and the website host is in the process of incorporating the website auditing services on a quarterly basis. She noted that the website and all the content prior to this agreement was in compliance with ADA. This agreement was to continue to stay in compliance as new content was added to the websites.

Mr. Williams stated that the Department of Justice still has not ruled on this and the District still does not know what the final outcome will be on what the District will be required to do or not do. A discussion took place and Ms. Carvalho mentioned that the Board at some

point will have a discussion about passing a resolution to remove or reducing the amount of content that goes out from the website.

FIFTH ORDER OF BUSINESS	Adjournment

There was no additional business to discuss. Ms. Carvalho requested a motion to adjourn.

On MOTION by Mr. Blakley, seconded by Mr. Johnson, with all in favor, the November 13, 2019 Meeting of the Board of Supervisors of the Blackburn Creek Community Development District was adjourned at 12:33 P.M.

Secretary/Assistant Secretary	Chairperson/Vice Chairperson

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Payment Authorizations 99 -- 101

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorizations 99-101

No. 99	PFM Group	$2,208.33	
No. 100	PFM Group - $17.64 Herald Tribune $145.78 Supervisor - $1,000.00	$1,163.39	
No.101	PFM	$154.00	

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 99
11/1/2019

Item No.

Payee

Invoice	General	Fiscal
No.	Fund	Year

1		PFM Group Consulting OM Fee: October 2019 Website Fee: October 2019

DM-10-2019-0010	$	2,083.33
DM-10-2019-0011	$	125.00
-

--FY 2019

TOTAL	$    2,208.33 

 IL	
Secretary I Assistant Secretary

2,208.33

RECEIVED NOV O 4 2019

pfm

Date		Invoice Number October 29, 2019	DM-10-2019-0010
Payment Terms		Due Date Upon Receipt	October 29, 2019

Bill To:

Blackbum Creek COD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd
Orlando, FL 32817 United States of America

Remittance Options:
Via ACH rorefen:edl:	�

RE:	District Management Fee: October 2019

Total Amount Due

RECEIVED OCT 3 0 2019

Company Address:
1735 Market Street 43rd Floor Philadelphia, PA 19103
+1 (215) 567-6100

Federal Tax ID: 81-1642478

Yia..Mait..
PFM Group Consulting LLC
PO Box 65126
Baltimore, MD 21264-5126 United States of America

$2,083.33

1	of	1

pfm

Date		Invoice Number October 29, 2019	DM-10-2019-0011
Payment Terms		Due Date Upon Receipt	October 29, 2019

Bill To:

Blackbum Creek CDD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd
Orlando, FL 32817 United States of America

RECEIVED OCT 3 0 2019

Company Address:
1735 Market Street 43rd Floor Philadelphia, PA 19103
+1 (215) 567-6100

Federal Tax ID: 81-1642478

Remittance Options:
Via ACH <preferred}:

RE:	Website Fee - October 2019

Total Amount Due

�	�
PFM Group Consulting LLC
PO Box 65126
Baltimore, MD 21264-5126 United States of America

1	of	1

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 100
11/15/2019

Item	Payee	Invoice	General	Fiscal
No.	No.	Fund	Year	

PFM Group Consulting
Reimbursables  : September 2019	OE-EXP-00480	$	17.64	FY2019

Sarasota Herald-Tribune
Legal Advertising on 11/06/2019	SC52G0RSL4	$	145.75	

fY2020
- 2bm
fl'2&28

Supervisor Fees -11/13/2019 Meeting
Dale Weidemiller	$	200.00
Pete Williams	$	200.00
John Blakley	$	200.00
Kevin Johnson	$	200.00
Jerald Dell	$	200.00	Pf

TOTAL	$	1,163.39

17.64
1,145.75

�	
Chairman / Vice Chairman

RECEIVED NOV 1 8 2019

Herald-Tribune
CLASSIFIED ADVERTISING RECEIPT

PFM GROUP CONSULTING LLC Venessa VENESSA RIPOLL 12051 CORPORATE BLVD

ORLANDO, FL 32817

Account: 10038491
Phone:	(407)723-5900 P.O.#:
Ad Taken By:	SC52
Receipt printed:	10/30/2019

Order Number	Class Number	Start Run	End Run	Run Times	
Lines	
DescriDtion	
SC52G0RSL4	0001	11-06-19	11-06-19	2	53	NOTICE OF PUBLIC MEETING BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT A meeting of
the Board of Supervisors of the Blackburn Creek Community Development District will be held,
November 13, 2019, at 12:15 p.m. at 5800 Lakewood Ranch Blvd., Sarasota FL	

Payment Detail	I	Pay Date	I	Type	I	Card or Check	#	I	Card	I	Exp	Amount	
Current Payment	I	I	I	I	I		
Order Price	$145.75	
Total Payments	-	$ 0.00	
Balance	=	$145.75	

Sarasota Herald-Tribune
(941) 953-5555 Classified (941) 361-4098 Fax
http;t twww,HeraldJribune,com
1777 Main St.
Sarasota, FL 34236

RECEIVED NOV O 8 2019

Sarasota Herald-Tribune's Copy

PFM GROUP CONSULTING LLC Venessa VENESSA RIPOLL 12051 CORPORATE BLVD

ORLANDO, FL 32817

Account: 10038491
Phone:	(407)723-5900 P.O.#:
Ad Taken By:	SC52
Receipt printed:	10/30/2019

Order Number	Class Number	Start Run	End Run	Run Times	
Lines	
Description	
SC52G0RSL4	0001	11-06-19	11-06-19	2	53	NOTICE OF PUBLIC MEETING BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT A meeting of
the Board of Supervisors of the Blackburn Creek Community Development District will be held,
November 13, 2019, at 12:15 p.m. at 5800 Lakewood Ranch Blvd., Sarasota, FL	

Payment Detail I Pay Date I	Type	I	Card or Check #	I Card  I	Exp		Amount	
Current Payment  I	I		I		I	I			
	
Order Price	$ 145.75	
Total Payments					-	$ 0.00	
Balance					=	$145.75	

AFFIDAVIT OF PUBLICATION
SARASOTA HERALD-TRIBUNE PUBLISHED DAILY
SARASOTA, SARASOTA COUNTY, FLORIDA

STATE OF FLORIDA COUNTY OF SARASOTA

BEFORE THE UNDERSIGNED AUTHORITY PERSONALLY APPEARED JM MITCHELL, WHO ON  OATH SAID SHE IS DIRECTOR OF ADVERTISING FOR THE SARASOTA HERALD-TRIBUNE, A DAILY NEWSPAPER PUBLISHED AT SARASOTA, IN SARASOTA COUNTY FLORIDA; AND CIRCULATED IN SARASOTA COUNTY DAILY; THAT THE ATTACHED COPY OF ADVERTISEMENT BEING A NOTICE  IN THE MATIER OF:

Legal description documented below:

IN THE	COURT WAS PUBLISHED IN THE SARASOTA EDITION OF SAID NEWSPAPER IN THE ISSUES OF:

11/6 Ix

AFFIANT FURTHER SAYS THAT THE SAID SARASOTA HERALD-TRIBUNE IS A NEWSPAPER PUBLISHED AT SARASOTA, IN SAID SARASOTA COUNTY, FLORIDA, AND THAT THE SAID NEWSPAPER HAS THERETOFORE BEEN CONTINUOUSLY PUBLISHED IN SAID SARASOTA COUNTY, FLORIDA, EACH DAY, AND HAS BEEN ENTERED AS SECOND CLASS MAIL MATTER AT THE POST OFFICE IN SARASOTA, IN SAID SARASOTA COUNTY, FLORIDA, FOR A PERIOD OF ONE YEAR NEXT PRECEDING THE FIRST PUBLICATION OF THE ATTACHED COPY OF ADVERTISEMENT; AND AFFIANT FURTHER SAYS THAT SHE HAS NEITHER PAID NOR PROMISED ANY PERSON, FIRM OR CORPORATION ANY DISCOUNT, REBATE, COMMISSION OR REFUND FOR THE PURPOSE OF SECURING THIS ADVERTISEMENT FOR PUBLICATION IN THE SAID NEWSPAPER.

SIGNED	 	

----

SWORN OR AFFIRMED TO, AND SUBSCRIB D BEFORE ME THIS               DAY OF w      .D., 20\ BY JM MITCHELL WHO IS PERSONALLY KNOWN TO ME.

�	
Notary Public

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NOTICE OF PUBLIC MEETING BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT
A meeting of the Board of Supervisors of the Blackburn Creek Community Development District will be held, November 13, 2019, at 12:15 p.m. at 5800 Lakewood Ranch Blvd., Sarasota, FL 34240. The meeting is open to the public and will be conducted in accordance with the pertinent provisions of Florida Law for Community Development Districts. The meeting may be continued to a date, time, and place to be specified on the record at the meeting. A copy of the agenda for the meeting may be obtained from PFM Group Consulting, LLC, 12051 Corporate Blvd., O ando, Florida 32817.
There may be occasions when one or more Supervisors will participate by telephone. At the above location there will be present a speaker telephone so that any Interested person can attend the meeting at the above location and be fully informed of the discussions taking place either In person or by telephone communci ation.
Any person requiring special accommodations at this meeting because of a disability or physical impairment should contact the District Office at (407) 723-5900 at least 3 calendar days prior to the meeting.
Each person who decides to appeal any decision made by the Board with respect to any matter considered at the meeting is advised that person will need a record of the proceedings and that accordingly, the person may need to ensure that a verbatim record of the proceedings is made, including the testimony and evidence upon which such appeal is to be based.
Vivian Carvalho District Manager
Date of pub : November 6, 2019

pfm

Bill To:

Blackburn Creek CDD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd
Orlando, FL 32817 United States of America

Remittance Options:
Via ACH {preferred}:	�

RE:	September 2019 Fedex - $8.74 September 2019 Postage - $8.90

Total Amount Due

Date	Invoice Number October 22, 2019	OE-EXP-00480
Payment Terms		Due Date Upon Receipt	October 22, 2019

Company Address:
1735 Market Street 43rd Floor Philadelphia, PA 19103
+1 (215) 567-6100

Federal Tax ID: 81-1642478

Yia...Ma.it.
PFM Group Consulting LLC
PO Box 65126
Baltimore, MD 21264-5126 United States of America

1	of	1

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3 of 3

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 235,251.08
Tracking ID	776061135974	Sender	Recipient	Transportation Charge	8.87
Service Type	Ppd, Domestic	Alexis Davis	PFM		Earned Discount		-0.98 Zone	02	PFM - Orlando East	LESLEY ALLISON	 	Fuel Surcharge		0.55
Packages	1	12051 Corporate Blvd	300 S ORANGE AVE	Total Charge	USO	$8.44	
Actual Weight	2.2 lbs	Orlando FL 32817	STE 1170				
Rated Weight
Delivered	3 lbs
Aug 26, 2019		ORLANDO FL 32801-337895				

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 235,251.08

Tracking ID	776061076787	Sender	Recipient	Transportation Charge	8.87	
Service Type	Ppd, Domestic	Alexis Davis	CYNTHIA PESANTES	Earned Discount	-0.98	
Zone	02	PFM - Orlando East	PFM	Fuel Surcharge	0.55	
Packages Actual Weight
Rated Weight	1
2.2 lbs 3 lbs	12051 Corporate Blvd
Orlando FL 32817	300 S ORANGE AVE STE1170
ORLANDO FL 32801-337895	Total Charge	USO	$8.44	
Delivered	Aug 26, 2019					

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 235,251.08

Tracking ID Service Type Zone Packages Rated Weight Delivered

776064639192
Ppd, Domestic 06
1
1 lbs
Aug 27, 2019

Sender
Amanda Lane
PFM - Orlando East 12051 Corporate Blvd
Orlando FL 32817

Recipient
LOCKBOX SERVICES-12-2657
U.S. BANK, N.A.- CDD 1200 ENERGY PARK DR EP-MN-OlLB
SAINT PAUL MN 55108-5101

Transportation Charge Earned Discount
Fuel Surchar ge	
Total Charge	USO
W 3 C l

9.68

0.60

-1.06
$9.22/3

Prepaid Subtotal	USO	$35.32	
FedEx Ground Miscellaneous Charges
(see summary section)	USO	$14.50	
Total FedEx Ground	USO	$49.82	

 £ \ueKnet r(\
 	Invoice Number	

Lreeh	

Account Number	Pa_ge

 	6-750-05188		 	6339-4889-5		2 of 3

FedEx Ground Shipment Summary By Payor Type

09/13	9.68	0.58	-1.06
G round-Prer	id Subtotal

9.20
$9.20

FedEx Ground Miscellaneous Char.9.es

TOTAL THIS INVOICE	USO	$23.70

FedEx Ground Prepaid Detail (Original)
The Earned Discount for this ship date has been calculated based on a revenue threshold of USD 233,121.12

Tracking ID	776238764367	Sender	Recipient	Transportation Charge	9.68	
Service Type	Ppd, Domestic	Amanda Lane	LOCKBOX SERVICES-12-2657	Earned Discount	-1.06	
Zone	06	PFM - Orlando East	U.S. BANK, N.A.- COD	Fuel Surcharge	0.58	

Packages	1	12051 Corporate Blvd	1200 ENERGY PARK DR	Total Charge	USD		
Rated Weight Delivered	1 lbs
Sep 17, 2019	Orlando FL 32817	EP-MN-OlLB
SAINT PAUL MN 55108-5101		-il L '6		

$9.2o/s

Prepaid Subtotal	USO	$9.20

FedEx® Billing Online
FedEx Billing Online allows you to efficiently manage and pay your FedEx invoices online. It's free, easy and secure. FedEx Billing Online helps you streamline your billing process. With all your FedEx shipping information available in one secure online location, you never have to worry about misplacing a paper invoice or sifting through reams of paper to find information for past shipments. Go to fedex.com to sign up today!

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FecEx ®

Invoice Number "i I	Invoice Date \ I	Account Number	\ 

Paoe

s-143-1s9_Q1

I [	Sep 19, 2019

c=s339	=-4B--=--=B9--=-5_

3 of 3
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The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 234,975.77
Tracking ID	776176054766	hnlln	Bwiwtn1	Transportation Charge	9.68
Service Type	Ppd, Domestic	Amanda Lane	LOCKBOX SERVICES-12-2657	Earned Discount	-1.06

1J ;),3 0

Zone	06	PFM - Orlando East	U.S. BANK, N.A.- COD	Fuel Surcharge	0.58

Packages	1	12051 Corporate Blvd	1200 ENERGY PARK DR	Total Charge	USO
Rated Weight	1lbs	Orlando FL 32817	EP-MN-01LB

Delivered	Sep 10, 2019	SAINT PAUL MN 55108-5101

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 234,975.77

.	$9 I'-/

Tracking ID	776171829011	hmm	llmltwd	Transportation Charge	8.23	
Service Type	Ppd, Domestic	Amy Champagne	Local Government Audits342	Earned Discount	-0.91	
Zone	03	PFM - Orlando East	Auditor General	Fuel Surcharge	0.49	
Packages Rated Weight
Delivered	1
1 lbs
Sep 09, 2019	12051 Corporate Blvd
Orlando FL 32817	111 West Madison Street
Claude Pepper Building, Room 401 TALLAHASSEE FL 32399	Total Charge	USO	$7.81	

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 233,121.12

Tracking ID Service Type Zone Packages Rated Weight Delivered

776178893460
Ppd, Domestic 02
1
1 lbs
Sep 10, 2019

bndlC
Lubna Sikder
PFM - Orlando East 12051 Corporate Blvd
Orlando FL 32817

BwllllD1
PRADIP GANDHI
AQUA ONE CDD 1651 WHITFIELD AVE
UNIT 200
SARASOTA FL 34243-395050

Transportation Charge	7.85
Earned Discount	-0.86
Fuel Surcharge	0.47
Total Charge	USO	$7.46

Prepaid Subtotal	USO	$36.13	
FedEx Ground Miscellaneous Charges
(see summary section)	USO	$14.50	
Total FedEx Ground	USO	$50.63	

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Pa!le
3 of 3

The Earned Discount for this ship date has been calculated based on a revenue threshold of USD 235,122.32
Tracking ID	776125632609	Sender	Recipient	Transportation Charge	9.68
Service Type	Ppd, Domestic	Amanda Lane	LDCKBOX SERVICES-12-2657	Earned Discount	-1.06 Zone	06	PFM - Orlando East	U.S. BANK, N.A.- COD	Fuel Surcharge		0.58

Orlando FL 32817	EP-MN-OlLB	·I •5- 3

Packages	1	12051 Corporate Blvd	1200 ENERGY PARK DR	Total Charge	USO	$9.20/ fo
Rated Weight	1 lbs	1l
Delivered	Sep 03, 2019	SAINT PAUL MN 55108-5101

Prepaid Subtotal	USO	$18.09	
FedEx Ground Miscellaneous Charges
(see summary section)	USO	$14.50	
Total FedEx Ground	USO	$32.59	

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Account Summary Report

Date Range : September 1, 2019 to September 31, 2019
Meter Group: All Meters
Meter lWOO - 1376538 OLD at ORLANDO, FL
Meter 4WOO - 0347354 at ORLANDO< FL	

C:	

Meter Details

LIKlllml	
ORIANDO, Fl

I MalarNaN
4WOO - 0347354

ISOI nurobat l Pl!!' Nwf'llNymba[ )
0347354	24978470

ORLANDO, FL	1 WOO - 1376538 OLD 1376538	24978470

Account Summary
Acalunt	SUbAa:ount
Blackbum Creek COD

Total diarjjed �]
15	$8.900

Grand Total	$8.900

Blackburn Creek COMMUNITY DEVELOPMENT DISTRICT

Date of Meeting: November 13, 2019

($200.00 per Supervisor per Meeting)

Board Members:	Present	Absent	Fee

Dale Weidemiller	Ct) . (5u

Pete Williams	 	
John Blakley	 	/	

--t1:>d-00· 00
-J:{ :20 0 <50

Kevin Johnson	 	/		&,Q.co.
Jerald Dell	 		aCD, 6\J

Total:	$/,C)IJO-

Approved For Payment:

 	1,woQQ

November 13, 2019
Date

BLACKBURN CREEK
COMMUNITY DEVELOPMENT DISTRICT

Payment At1l!Mrinlion No.101

11122/.W19

Item		oioe	General	Fiscal	
No		No.	FIBI	Year	

1	PFM Grau p Constdting
Raimtltlts.abMti: S4!ip,tember 2019	

1 81	

$	Hi4.00		
					
		TOTAL	$	15',QO		
			
154.00	
FY21lt•	

Sftcretary f Assistant Seaetary	Chail'Man I Vice C:lhairman

pfm
BIIITo:

Blackburn Creek CDD

RECEIVED NOV 2 2 2019

/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd
Orlando, FL 32817
United States of America	

Remittance Options:
C.1:1.rorererredl·	1/iil..Wiee;_

RE:	Billable expenses through September 2019. Expenses
Total Amount Due

Date	Invoice Number
November 12, 2019	106881
Payment Tenns	Due Date
Upon Receipt	November 12, 2019

Company Address:	
1735 Market Street 43rd Floor Philadelphia, PA 19103
+1 (215) 567-6100	
Federal Tax ID: 81-1642478	

llia..Mwl.:..
PFM Group Consulting LLC PO Box 65126
Baltimore, MD 21264-5126
United States of America	

$154.00
$154.00	

of	2

Qate	lnvelce Number	
November 12, 2019	106881	
Payment Terms	Due Date	
Upon Receipt	November 1, 2  2019	

lr	teaorv

Worker

Expense Supporting Detail
Transactron Date

Amount Billed

pfm

Advertising	Jennifer Walden	09/25119		$154.00 Advertising
Tota l Expenses : $154 .00

2	of	2

0	Herald-Tribune
CLASSIFIED ADVERTISING RECEIPT

PFM GROUP CONSULTING LLC Venessa VENESSA RIPOLL 12051 CORPORATE BLVD

ORLANDO, FL 32817

Account: 10038491
Phone:	(407)723-5900 P.O.#:
Ad Taken By:	SC52
Receipt printed:	09/25/2019

Order Number	Class Number	Start Run	End Run	Run Times	
Lines	
Description	
SC52G0RQVG	0001	10-02-19	10-02-19	2	56	Notice of Meetings Blackburn Creek Community Development District The Board of Supervisors of the Blackburn Creek Community  Development  District will
hold their meetings for the 2020 Fiscal Year at 5800 Lakewood Ranch Blvd Sarasota, FL 34240 at 12:15 o	

Payment Detail I Pav Date I	Tvpe	I	Card or Check #	I Card	I	Exp	Amount	
Current Payment I 09/25/2019 I	CARD	I	xxxxxxxxxxxx4022	I MC	I	01/23		$ 154.00	
Order Price	$ 154.00	
Total Payments						-	$ 154.00	
Balance						=	$ 0.00	

Sarasota Herald-Tribune
(941) 953-5555 Classified (941) 361-4098 Fax
h  ptt:   //	n   = :  - bune.   cmo
Sarasota, FL 34236

Sarasota Herald-Tribune's Copy

RECEIVED OCT O 4 2019

PFM GROUP CONSULTING LLC Venessa VENESSA RIPOLL 12051 CORPORATE BLVD

Account: 10038491
Phone:	(407)723-5900 P.O.#:

ORLANDO, FL 32817

Ad Taken By: Receipt printed:

SC52
09/25/2019

Order Number	Class Number	Start Run	End Run	Run Times	
Lines	
Description	
SC52G0RQV G	0001	10-02-19	10-02-19	2	56	Notice of Meetings Blackburn Creek Community Development District The Board of Supervisors of the Blackburn Creek Community Development District will hold their meetings for the 2020 Fiscal Year at 5800
Lakewood Ranch Blvd Sarasota FL 34240 at 12:15 o	

Pavment Detail	I	Pav Date	I	Tvpe	I	Card or Check #	I	Card	I	Exp	Amount	
Current Payment	I	09/25/2019	I	CARD	I	xxxxxxxxxxxx4022	I	MC	I	01/23		$ 154.00	
	
Order Price	$ 154.00	
Total Payments											-	$ 154.00	
Balance											=	$ 0.00	

AFFIDAVIT OF PUBLICATION
SARASOTA HERALD-TRIBUNE PUBLISHED DAILY
SARASOTA, SARASOTA COUNTY, FLORIDA

STATE OF FLORIDA COUNTY OF SARASOTA

BEFORE THE UNDERSIGNED AUTHORITY PERSONALLY APPEARED JM MITCHELL, WHO  ON  OATH SAID SHE IS DIRECTOR OF ADVERTISING FOR THE SARASOTA HERALD-TRIBUNE, A DAILY NEWSPAPER PUBLISHED AT SARASOTA , IN SARASOTA COUNTY FLORIDA; AND CIRCULATED IN SARASOTA COUNTY DAILY; THAT THE ATTACHED COPY OF ADVERTISEMENT BEING A NOTICE  IN THE MATTER OF:

Legal description documented below:

IN THE	COURT WAS PUBLISHED [N THE SARASOTA EDlTION OF SAID NEWSPAPER lN THE lSSUES OF:

10/2 lx

AFFIANT FURTHER SAYS THAT THE SAID SARASOTA HERALD-TRIBUNE IS A NEWSPAPER PUBLISHED AT SARASOTA, IN SAID SARASOTA COUNTY, FLORIDA, AND THAT THE SAID NEWSPAPER HAS THERETOFORE BEEN CONTINUOUSLY PUBLISHED IN SAID SARASOTA COUNTY, FLORIDA, EACH DAY, AND HAS BEEN ENTERED AS SECOND CLASS MAIL MATTER AT THE POST OFFICE IN SARASOTA , IN SAID SARASOTA COUNTY, FLORIDA, FOR A PERIOD OF ONE YEAR NEXT PRECEDlNG THE FIRST PUBLICATION OF THE ATT ACHED COPY OF ADVER TISEMENT ; AND AFFIANT FURTHER SAYS THAT SHE HAS NEITHER PAID NOR PROMISED ANY PERSON , FIRM OR CORPORATION ANY DISCOUNT , REBATE, COMMISSION OR REFUND FOR THE PURPOSE OF SECURING THIS ADVERTISEMENT FOR PUBLICATION IN THE SAID NEWSPAPER.

_lA   ' _""-

_

SIGNED  	;I:,M., W'/_/J M   l Jw}i _J_     _

SWORN OR AFFIRMED  TO, AND SUBSCRIBED BEFORE ME THI2S BY JM MITCHELL WHO IS PERSONALLY KNOWN TO ME.

DAY oi() U J,µ , A.D., 2ol_C\

Notice of Meellncs Blackbum Creek Community Development District

The Board of Supervisors of the Blackburn	Creek	Community Devolopment District will hold their meetings for the 2020 Fiscal Veer at 5800 Lakewood Ranch Blvd, Sarasota, FL 34240 at 12:15 p.m. each month as follows:
October 9, 2019
November 13, 2020
December 11, 2020
January 8, 2020
February 12, 2020
March 11, 2020
April 8, 2020
May 13, 2020
June 10, 2020
July 8, 2020
August 12, 2020
September 9, 2019

There may be occasions when one or more Supervisors will participate by telephone, At the above  locatlon  there will  be  present  a speaker  terept,ono  so
that any Interested person can a11ond the
meeting at the above location  and be full y Informed of the discussions ta ing place either in person or by tolophone communication.
Any person roqu!ring special accommodallons at this meeting because or a disability or phys ical lmpalrmant should contact the ,O strict omce at (407) 723-5900 at least live
calendar days prior to the meeting,

Each person who decided to appeal any action taken at these meellngs Is advised that person will need a record of the procaadings end that accordingly, the porson may need to ensure that a verbatim, ecord of the proceedings is
mado , Including the tsstimony and evidence upon which such appeal Is to be based.

Vivian Carvalho District Manager
Date of pub : October 2, 2019

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Requisitions 2018-115 – 2018-116

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratifications of Requisitions 2018-115 — 2018-116

2018-115	Neal Communities	$189,348.00	
2018-116	Forsberg Construction, Inc.	$56,994.59	

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2018 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackbum Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, For Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of March I, 2018 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2018-115

Neal Communities of Southwest Florida 5800 Lakewood Ranch Blvd.
Sarasota, FL 34240

Amount Payable:	$189,348.00

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs of Issuance, if applicable):

Reimbursement of developer funded construction cost for Curb Ramp, Modified F Curb, and Type "M" Curb for GP Phase 3C, consistent with the Supplemental Engineer's Report.

The undersigned hereby certifies that [obligations in the stated amount set  forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2018 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2018 Capital Improvement Plan and represents a Cost of the 2018 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that  has  not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such requisition contains no  item representing payment on account of any retained percentage which the District is at  the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbmsements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s)  from the vendor of  the property acquired  or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By	
Authorized Officer

CONSULTING  ENGINEER'S  APPROVAL FOR
NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance,  or for  payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2018 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2018 Capital Improvement Plan segment and portion of the 2018 Capital Improvement  Plan  with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplementa l Indenture, as s uch report shall have been amended or modified on the date hereof.

Cons	    	

Nal Camnurriries
5800 I..l..owooc! lu nch Blvd N
S.u2so b.,FL 34240
(p)( 941)	lll l

NEALCOMMUNTI IES
Building. Home. Life.

Name
Onier Date

Purchase Order: 4222
Blackb.rn Creek CDD - FOl'sberg - CDD Eigtie Cub- RoadwOl'k
11/13/l 0lS	Last ReTised Date

!Vendor	IIJob

340- 3C

B1acktun Creek  Cooumdy Developnm District	Active Under Developnent crthGrandPahn Phase Phase 3
12386 Sagewood Dr
\ eri ce, Fl 34293
PM   Randy Olson
ols<n@nealcomm\rities.can

Plan / Eleu.tion Plan Orientation Comments

Additional Information
Tu Rate Retention Pe rcent
Crecitingcub to be reimbirsed bythe CDD

Line I tern Detail

0.0000%
0.0000

f

I ---

Resource Description

I

0820 Roadwork

-

Curb Ramp Mod ed F Curb
Type "M" Curb - LF

co	Quantl	Unit  ILS/Unit Pri}c		Total	] 0		-=-; 0.00I   Each  r	$78  0.00	($7,800.00)

I

0	-13215.00  LF	$1 0.80   ($1 42,722.00)1
0	-3595.00  LF	$1 0.80 ($ 38 ,826.00

Invoiced
$0.00

$0
$0.001

Dnnr	D n.w Amounts

P a ym ent Information

Terms and Conditions

Sllbtotal: ($189,348 .00)
Total Tu:		S0.00 Purchase Onler Tot al (St89,3 8.00) l nToi ced To Date	S0.00

By tlis reference ths iucmse 0l'der becomes anaddencbn dthe originalccnract. At tenns andconcitions « that com act aPP., to ths PO. Please review carefuly before sigring
 		Copyright 2017 Leverance LLC.	 	

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2018 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of March !, 2018 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2018-116

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950

$56,994.59

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs ofissuance, if applicable):

Grand Palm, Phase 2C Application No. 13 (See attached Invoice). This Application for Payment is approved based on a site and observation of work.

The undersigned hereby certifies that [obligations in the stated amount set  forth  above have been incurred by the District, that each disbursement set forth above is a  proper chai-ge against the Series 2018 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2018 Capital Improvement Plan and represents a Cost of the 2018 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that  has  not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof

Blackburn Creek Community Development District

The undersigned hereby further certifies that such reqms1tlon contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance  Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By Au'edOfficer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs ofissuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2018 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2018 Capital Improvement Plan segment and portion of the 2018 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

Co1ns1ul/t4ing. Eng.ineer	/ "

CONTRACTOR'S  APPLICATION  FOR PAYMENT

PROJECT	Grand Palm Phase 2C (CDD Portion)

ENGINEER	Kimley-Horn and Associates,Inc. OWNER	Blackburn Creek CDD
5800 Lakewood Ranch Boulevard Sarasota, FL 34240	REQUEST NO

NTP DATE
Contract Tim SUBSTANTIA FINAL

CONTRACT	.

e L

OR	13

March 26, 2018
337 Days
February 26, 2019
March 26, 2019

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950	
FOR WORK COMPLETED FROM	10/1/2019	TO	10/31/2019	

CONTRACT PAYMENTSUMMARY

Original Contract Amount
Change Orders:	2,104,919.0 0	
Change Order Summary		
Number	Date Approved	Additive	Deductive		
3	5/29/2018	9,012.00			
4	11/26/2018	171,420.00			
		.			
		.			
Subtotals	180,432.00	-		
Net Change Order Subtotal (Additive less Deductive)
Current Contract Amount (Original Amount+ CO's)	180,432.00
2,285,351.00

1,752,494.76
1,695,500.17
56,994.59	

Value of Work in Place
Value of Material Purchased by Owner Total Earned (%& $)
Retainage (%& $)	Previous Status	Current Sta tus		
	2,272,562.50
487,825.48
78%	1,784,737.02
5%	89,236.85	100%	2,285,351.00
487,920.48
79%	I,797,430.52
2.5%	44,935.76		
Net Earned (Total earned minus retainage)	1,695,500.17	I,752,494.76 Total Previous Estimates
AMOUNT DUE THIS PERJOD		

CERTIFICA TION OFCONTRACTOR

The undersigned Contractor hereby swears under penalty of perjury that (I) alI previous progress payments received from the Owner on account of Work performed under the Contract referred to above have been applied by the undersigned todischarge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered I through 12 inclusive; and (2) all materials and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment arc free and clear of all liens, claims, security interests and encumbrances; and (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective as that term is defined in the Contract Documents.

Ashly Wester
Notary Public, State ofF lorida
My Commission expires August 23, 2020		Punta Gorda, Flor ida 33950 Sworn and subscribedto me this	Phone(941) 637-8500

1st day of November AD 2019	1	! ! .,,ta el

o f Florida	Fax (941) 639-1073

(STAMP I SEAL)

Payment of the above AMOUNT DUE THIS APPLICATION is recommended.

Engineer Owner

DATE

    l\_w    \	
H

Project:	Grand  Palm Phase 2C (CDD Portion)	Forsberg C nstruction, Inc.	Pay Request No.	13
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	10/1/2019
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	10/31/2019
PREVIOUS WORK	WORK TIDS PERIOD	WORK TO DATE	PERCENT
ITEM		DESCRIPTION			UNIT	CONTRACT							COMPLETE NO.	CODES		OFWORK	QUAN  iuNJT	PRICE		TOTAL	QTY	VALUE	QTY	VALUE	QTY	VALUE		%

2	910
3	910

24" RCP
30" RCP

911   LF
1,041 l  LF

65.00
84.00

59,215.00
87,444.00

911.0	59,215.00
1041.0	87,444.00

0.00	-	'	911.00,	59,215.00
0.00	-	I	1041.00	87,444.00

100.00%
100.00%

4	910

36" RCP

2561 LF

116.00

29,696.00

256.0	29,696.00

0.00	-	!	256.00,	 29,696.00	10-0.00%

5	910

42" RCP

1,295 LF

151.00

195,545.00

1295.0	195,545.00

0.00	-

1295.00	195,545.00

100.00%

6	910
7	910
8	910
9	910
IO	910
11	910
12	910

34"x53" RCP
Grated Swale Inlet
Type "F" Inlet 36" x 48" (inside size) Type "M" Inlet 36" x 48" (inside size) Type "M" Inlet 42" x 60" (inside size)
24" Flared End Section
'
30" Flared End Section
'

381  LF
I   EA
2   EA
18   EA
4   EA
4     EA
6     EA

226.00
3,400.00
4,200.00
4,200.00
6,900.00
4,100.00
4,500.00

86,106.00
3,400.00
8,400.00
75,600.00
27,600.00
16,400.00
27,000.00

381.0	86,106.00 :	0.00	-
1.0	3,400.00  i	0.00	-
2.0	8,400.00 !	0.00	-
18.0	75,600.00 i	0.00	-
4.0	27,600.00	0.00	-
4.0	16,400.00	0.00	-
6.0	27,000.00	0.00	-

381.00	86,106.00
1.00	3,400.00 I
2.00	8,400.00
18.00	75,600.00
4.00	27,600.00
4.00	16,400.00
6.00	27,000.00

100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%

13	910
14	910
15	;	910

36"  Flared End Section	I	2	EA
42" Flared End Section	8   EA
34"x53" Flared End Section	2    EA

5,800.00
6,600.00
6,600.00

11,600.00
52,800.00
13,200.00

2.0	11,600.00
8.0	52,800.00
2.0	13,200.00

0.00	-
0.00	-
0.00	-

2.00	11,600.00
8.00	52,800.00
2.00	13,200.00

100.00%
100.00%
100.00%

16	I	910
17	;	910
18	910

Junction Box
Small Control Structure Medium Control Structure

2   EA
I   EA
2    EA

7,200.00
5,600.00
10,000.00

14,400.00 I	2.0	14,400.00
5,600.00 i	1.0	5,600.00
20,000.00 I	2.0	20,000.00

0.00	-
0.00	-
o.ool	-

2.00	14,400.00
1.00	5,600.00
2.00	20,000.00

100.00%
100.00%
100.00%

19	910
20	910
21	910

Swale from Bubbler to Wetland
Rip-Rap at Bubbler
Connect to Existing Structure

221	LF
63   SY
I    LS

12.00 !	2,652.00
100.00 i	6,300.00
5,000.00 I	5,000.00

221.0	2,652.00
63.0	6,300.00
I.Oi	5,000.00

o.oo,	-
0.001	-
0.00	-

221.00	2,652.00
I	63.00	6,300.00
I	1.00	5,000.00

100.00%
100.00%
100.00%

25	910
26	910
27	910

6'

Modified F Curb TypeMCurb Curb Ramp

1,700	LF
12,600	LF
IO	EA

16.20 :	27,540.00
10.80 i	136,080.00
780.00 i	7,800.00

1100.01	27,540.00
12600.0i	136,080.00
10.0I	7,800.00

0.00	-	i	1700.00	27,540.00
0.00	- ,	12600.00	136,080.00
0.00	-	10.001	1,800.00 I
-	I	12.00	67,200.00   i

100.00%
100.00%
100.00%

100.00%

2	960

Manholes 6' - 8'

I EA

6,200.00 i	6,200.00

1.0	6,200.00

0.00

.  -	1.001

6,200.00 	100.00% 

3	960	IManholes 8' - IO'
4	960	iManholes 10' - 12'
5	960	Manholes 12' - 14'
6	960	Manholes 14' - 16'
7	960	Manholes 16' - 18'
960	8"  PVC SDR 26  Gravity Sewer O' - 6'
960	8" PVC SDR 26 Gravity Sewer 6' - 8'
IO	960	8" PVC SDR 26 Gravity Sewer 8' - 10'

EA
EA
4    EA
2   EA
I   EA
1,389   LF
952   LF
909   LF

7,000.00
7,800.00
9,000.00
10,500.00
12,200.00
34.00
52.00
70.00

28,000.00
39,000.00
36,000.00
21,000.00
12,200.00
47,226.00
49,504.00
63,630.00

4.0	28,000.00
5.0	39,000.00
4.0	36,000.00
2.0	21,000.00
1.0	12,200.00
1389.0	47,226.00
952.0	49,504.00
909.0	63,630.00

0.00	-
0.00	-
0.00	-
0.00	-
0.00	-
0.00	-
0.00	-
0.00	-

4.oo: 5.00
4.00
2.00
1.00
1389.00
952.00
909.00

28,000.00  I	100.00%
39,ooo.oo  I	100.00%
36,000.00	100.00%
21,000.00	100.00%
12,200.00	100.00%
47,226.00	100.00%
49,504.00	100.00%
63,630.00	100.00%

11	960

8" PVC SDR 26 Gravity Sewer 10'  -  12'  ' 1	858	LF

87.00

74,646.00

858.0	74,646.00

0.001	-

858.00	74,646.00

100.00%

12	960
13	960
14	I	960
15	960
16	960

11/1/2019

8" PVC SDR 26 Gravity Sewer 12' - 14'  i	815   LF
8" PVC SDR 26 Gravity Sewer 14' - 16'	800   LF
8" PVC SDR 26 Gravity Sewer 16' - 18'	355   LF
Single sewer service	21    EA
Double sewer service	52    EA

101.00
130.00
160.00
1,500.00
1,500.00

82,315.oo I	815.0	82,315.00
104,000.00 i	800.0	104,000.00
56,800.00	355.0	56,800.00
31,500.00	21.0	31,500.00
78,000.00	52.0	78,000.00

Page 1 of2

O.OOi	-
0.001	-
0.00	-
0.00	-
0.00	-

815.00	82,315.00 i	100.00%
800.00	104,ooo.oo I	100.00%
!	355.00i	56,800.00 :	100.00%
21.00i	31,500.00	100.00%
52.00	78,000.00	100.00%

Schedule of Values

Project: Owner: Engineer:

ITEM	I
NO.	CODES

Grand Palm Phase 2C (COD Portion) Blackburn Creek COD
Kimley-Horn and Associates, Inc.

DESCRIPTION	I	I	I
OFWORK	_j  Q_UAN IUNJT
nnection to existing gravity sewer

UNIT	I
PRICE

Forsberg Construction, Inc.
645 Charlotte Street Punta Gorda, FL 33950

PREVIOUS WORK

I

CONTRACT
TOTAL	QTY	VALUE

WORK THIS PERIOD

_Q_TY	VALUE
0.00
0.00

Pay Request No. For work from:
To:

WORK TO DATE

_Q_TY	VALUE
2.00
6078.00

13
10/1/2019
10/31/2019

PERCENT COMPLETE
%
100.00%

: ., ;_;;·r '.·'. .• :_   :·.:'.:'.·-·:i}1if! Jht:t-(:t;  1 1i; :' 1: 111!!  !!iii!::111!1i 11·1t·	1·1  1'  H,,,  -·
6" PVC DR-18, C900 Water Main	139,360.00	o.oo'	J	5360.00	139,360.00	100.00%!

	56,000.00 i		56,000.00	0.00		I		2000.00I	56,000.00	100.00%	
											
II	EA	1,800.00;	19,800.00	11.0'	19,800.00	0.00				11.00!	19,800.00	100.00%	
4	EA	2,000.00·	8,000.00	4.0	8,000.00	0.00				4.00'	8,000.00·	100.00%	
7,	EA.	6,000.00	42,000.00	7.0	42,000.00	0.00	 		_j_		7.00	42,000.00	100.00%	
'	791	EA'	1,000.00	79,000.00	79.0	79,000.00 I	0.00		-		79.00I	79,000.00:	100.00%	

,_ 2	1010	8" PVC DR-18, C900 Water Main
1010 :6"Gatevalveandvalvebox
1010	8" Gate valve and valve box
 	5	1010	Fire Hrdrant Assembly
6	1010      iSinglewaterservice(Short)	'
7	1010	Singlewaterservice(Long)	46, EA	1,200.00	55,200.00	46.0	55,200.00:	0.00		-	-46.00!	55,200.00 i	100.00%	
_8_	1010	8"x8" Taeping Sleeve and Valve	I! EA	7,800.00	7,800.00	1.0	7,800.00 '	0.00	_	-	1.00	7,800.00	100.00%	
9	1010	Blowoff Assembl    		2 EA	1,200.00	2,400.00	2.0	2,400.00	0.00		-	2.00	2,400.00	100.00%	

7,360    LF  I		2.10 I	15,456.00 ,	7360.0	15,456.00	0.00!	··-	
7,360    LF	3,695.50
,J!ii!!i!i!ii!11:iliii1:!i!!lil;i:i f j JY!1!:I:ij; 1 '! 1 1  j!P'
1	

4.00	10,000.00	100.00%	
7360.00	15,456.00 ·	100.00%	
7360.00I	13,984.00 I	100.00%	

IO	1010	Tie-in to existing Water Main	4   EA  I	2,500.00	10,000.00 I	3.0	7,500.00	1.00	2,500.00

 	11	I	1010	Pressure testin_i;_ of main-	i 
12	1010	Chlorination and bacteriological

- 10,288.50 I

--     .•'   -:   '   11 !!i'i     11 ' :'·.	1ili!1!!l:i!  i{:!:!!!1li J ';?

I	1260	Florida Trench Safety Act	I	I'   LS	100.00'	100.00	1.0i	100.00 	0.00

 	1.00	100.00      ··1-·0·0·.0-0-%--

r-----c----
3
4

260	: Construction stakeout
260	·Record drawings/ As-Built Survey

I' LS	23,400.00 I	23,400.00	1.0I	23,400.00 	0.00
I LS    '	7,200.001	7,200.00	LOI	.	7,200.00	0.00

.	 1.00	23,400.00	100.00%
I	1.001	7,200.00  1	100.00%1

5	510	i Mobilization
 	TOTAL

PHASE3C DRAINAGE SANITARY SEWER
WATER DISTRIBUTION MISCELLANEOUS

TOTAL

260
510
910
960

I LS	50,000.00	50,000.00	1.0 I	50,000.00 1	O.OQ_
2,285,351.00	2,272,562.50

$	920,918.00	$	920,918.00	$	$	920,918.00	100.00%	
$	834,733.00	$	834,733.00	$	$	834,733.00	100.00%	
$	449,000.00	$	436,211.50	$	12,788.50	$	449,000.00	100.00%	
$	80,700.00	$	80,700.00	$	$	80,700.00	100.00%	
$ 2,285,351.00	$ 2,272,562.50	$	12,788.50	$ 2,285,351.00	100.00%	

Summary of Work Classifications

Summary of Accounting Codes

$	30,600.00	$	30,600.00	$
$	50,000.00	$	50,000.00	$
$	920,918.00	$	920,918.00	$
$	834,733.00	$	834,733.00	$

 	1.001	50,000.00 !	100.00%
12,788.50	2,285,351.00	100.00%

$	30,600.00	100.00%
$	50,000.00	100.00%
$	920,918.00	100.00%
$	834,733.00	100.00%

1010
1260

TOTAL

$	449,000.00	$	436,211.50	$	12,788.50
$	100.00	$	100.00	$

$   2,285,351.00	$   2,272,562.50	$	12,788.50

$	449,000.00	100.00%1
$	100.00	100.00%

$   2,285,351.00	100.00%

Project:  Grand Palm Phase 2C (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	13
Owner:   Blackburn Creek COD	645 Charlotte Street	For work from:	10/1/2019
Engineer: K.imley-Horn  and Associates, Inc.	Punta Gorda, FL 33950	To:	10/31/2019	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	I

jUNIT	MATERIAL
UNIT PRICE	PURCHASE
ORDER TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

_QTY	VALUE	WORK TO DATE

_QTY	VALUE	PERCENT
COMPLETE!
%	
I	I.a DRAINAGE (excludes FDOT final pipe inspection)
18" RCP	28 LF	17.12	

1

!	479.36	28.00	1

479.36		0.00	-	i	i   	
28.00	479.36	 	
100.00%	
2	24" RCP	I	911    LF	22.85  I	20,816.35	911.00	20,816.35,	0.00	-	911.00	20,816.35	100.00%
3	30" RCP	_   1,041    LF	32.38	33,707.58	1041.00!	33,707.58  '	0.00	-	1041.00	33,707.58	100.00%
4	36" RCP	256    LF	45.29	11,594.24	256.00	11,594.24	0.00	-	,	256.00	11,594.24	100.00%
5	42" RCP	---	1,295    LF	56.19 -	72,766.05	1295.00	72,766.05	0.00	-	1295.00,	72,766.05	100.00%
6	34"x53" RCP	381 i  LF	96.63	36,816.03	381.00,	36,816.03	0.00	-	381.00:	36,816.03	100.00%

7	Grated Swale Inlet	.	I  I  EA	666.35	666.35	1.00	666.35	0.00	-	1.00i	666.35	100.00%
       8           T,'Jl_e "F" Inlet 36" x 48" (inside size)	!	2    EA	905.83 '	1,811.66 I	2.00	1,811.66	0.oo:	-	2.00	1,811.66 :"	100.00%
9	'Type "M" Inlet 36" x 48" (inside size)	18    EA	1,330.91	23,956.38 ·	18.00	23,956.38 I	_ 0.00:	-	18.00	_23,956.38	100.0
10	Type"M"Inlet42"x60"(insidesize)	I      _	4   EA	1,330.91	5,323.64 i	4.00 	5,323.64 !	0.00!	-	4.00	5,323.64'	100.00%
11	24" Flared End Section	4    EA	961.40	3,845.60	4.00	3,845.60	0.00i	-	4.00	3,845.60	100.00%
12	30" Flared End Section	I	6     i     EA	1,249.63	7,497.78	6.00	7,497.78 I	0.00	-	I	6.00	7,497.78	100.00%
13	36" Flared End Section	i	2    EA	1,483.90	2,967.80	2.00	2,967.80	0.00·	-	I	2.001	2,967.80	100.00%
14	42" Flared End Section	8    EA	1,719.03	13,752.24	8.00'	13,752.24	·o.OO	-	8.00i	13,752.24	100.00%
15	34"x53" Flared End Section	2    EA  !	1,864.95	3,729.90	2.00	3,729.90	0.00	-	2.00!	3,729.90	100.00%
16	!Junction Box	.	2    EA	1,734.68	3,469.36	2.00i	3,469.36.	0.00	-	2.00	3,469.36	100.00%
17	1 Small Control Structure	I   -EA	1,572.63	1,572.63	LOOI	1,572.63	0.00	-	--1.00I	1,572.63 !	100.00%
 	18	'Medium Control Structure	I	2  j        EA	2,782.59 I	5,565.18	2.001	5,565.18	0.00'	-	I	2.001	5,565.18 j	100.00%
 	Lb   SANITARY SEWER	'	I	'   	
1	I	Manholes0'-6'	12'  EA	1,320.25.	15,843.00	12.00	15,843.00	0.00_	-	I	12.00	15,843.00 i	100,_()0%
2	Manholes 6' - 8'	_	I	EA  !	1,572.20 !_	1,572.20 I	1.00	1,572.20	0.00'	-	LOO	1,572.20	100.00%
'	3	Manholes 8' - 10'	4    EA  :	1,866.25  !	7,465.00	4.00	7,465.00	0.00	-	4.00	7,465.00	100.00%
,	4	Manholes 10' -12'	,	5	EA	2,152.00.i	10,760.00	5.00i	10,760.00	0.00	-	'	5.00!	10,760.00	100.00%
'	5	Manholes 12' -14'	,	4    EA  !	2,243.00	8,972.00	4.00	8,972.00	0.00_	-	i	-        4.00i	8,972.00	100.00%1

6	Manholes 14' - 16'	2    EA   1	2,660.55	5,321.10	2.00·	5,321.10	0.00	-	2.001	5,321.10	100.00%'
,	7	Manholes 16' - 18'	I	EA	2,809.00	2,809.00	1.00_	2,809.00	0.001	-	1.00	2,809.00	100.00%

 	 r

8	18"PVCSDR26GravitySewer0'-6'	1,389   LF-	4.06	5,639.34	1389.001	5,639.34	0.00,	-	1389.00'  --	5,639.341	100.00%
1	9	:8"PVCSDR26GravitySewer6'-8'	952    LF	4.06  I_	3,865.12	952.001	3,865.12	o.oo!	--  -	952.00	3,865.121	100.00%
IO	8" PVC SDR 26 Gravity Sewer 8' - IO'	909    LF	4.06	3,690.54	909.00I	3,690.54	0.00 I	-	I	909.00-	3,690.54-	100.00%
11	'8" PVC SDR 26 Gravity Sewer 10' - 12'	858  I  LF   :	4.061	3,483.48 I	858.00	3,483.48  I	o.oo:	-	I	858.00	3,483.48,	100.00%
12	8"PVCSDR26GravitySewer12'-14'	815  I  LF   ,	4.06'	3,308.90:	815.00	3,308.90 I	0.00,	-	-	1	815.00	3,308.90	100.00%

r

13	8" PVC SDR26 Gravity Sewer 14' - 16'	800-      LF	4.06	3,248.00	800.00	3,248.00  i	0.00	-	800.00	3,248.00	100.00%
14	8" PVC  SDR26 Gravity  Sewer 16' -18'	355    LF	4.06 !	1,441.30	355.00i	1,441.30 I	0.00	-	i	355.00	1,441.30	100.00%
15	Single sewer service	21  'EA	265.72 I	5,580.12	21.00:	5,580.12	0.00	-	21.00	5,580.12	100.00%
 	16	Double sewer service	52  I  EA  1	310.19 I	16,129.88	52.00;	16,129.88	0.00	-   -i	52.00	16,129.88 !	100.00%
 	1.c     WATERDISTRIBUTION	!	!	1	I	i   	
1	I	'6" PVC DR-18, C900 Water Main	1	5,360  'LF	4.54 i	24,334.40	5360.00	24,334.40 i	0.00!	-	5360.00	24,334.40	100.00%
2	i8" PVC DR-18, C900 Water Main	2,000  :  LF	9.10	18,200.00  i	2000.00	18,200.00,	0.00	-	i	2000.00	18,200.00	100.00%
'	3	6" Gate valve and valve box	11 · EA	576.75 :	6,344.25 I	I 1.00 I	6,344.25	0.00	-	!	I1.00	6,344.25	I00.00%
4	I 8" Gate valve and valve box	4 ,   EA	839.13 1	3,356.52	4.00!	3,356.52	0.00	-	i     --	4.00'	3,356.52	100.00%

Project: Grand Palm Phase 2C (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	13	
Owner: Blackburn Creek CDD	645 Charlotte Street	For work from:	10/1/2019	
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	10/31/2019	

MATERIAL	PURCHASE

PREVIOUS WORK

WORK THIS PERIOD

WORK TO DATE

PERCENT

5
6
7
8
10

Fire Hydrant Assembly Single water service (Short) Single water service (L :mg)
8"x8" Tapp!ng Sleeve and Valve Tie-in to existing Water Main TOTAL

7	EA

15,555.47 	7.00 

I

46

EA

!

EA I

1,767.97 	1.00	

.  -· 15,555.47
24,505.80
16,412.34
1,767.97

0.00

-

79 EA

2,222.21   	
310.20
356.79
1,767.97

'

24,505.80
16,412.34

79.00
46.00,

0.00 -·---- ------- -

0.00
0.00

7.001
79.00!
4

I 	4 _£": '

-
-

89.62

-··

358.48
460,302.34

3.00I  	268.86	1.00 	,,   8,, 9.62

$

$

460,212.72

$

89.62

i:-il

.

I

$

15,555.47  !	100.00%
24,505.80	100.00%
_1§,412.34	100.00%
1,767.97	100.00%
358.48	100.00%
460,302.34  I	100.00%

Summary

ITEM	DESCRIPTION			UNIT	ORDER							COMPLETE	
NO.	OF WORK	QUAN	[!NIT	PRICE	TOTAL	QTY	VALUE	QTY	VALUE	QTY	VALUE	%	

Ferguson Waterworks	$	157,221.91	$	157,132.29	$	89.62	$	157,221.91	100.00%	
Cast Systems	$	95,107.50	$	95,107.50	$	-	$	95,107.50	100.00%	
County Materials	$	207,972.93	$	207,972.93	$	-	$	207,972.93	100.00%	
6% State Sales Tax	$	27,618.14	$	27,612.76	$	5.38	$	27,618.14	100.00%	
TOTAL	$	487,920.48	$	487,825.48	$	95.00	$	487,920.48	100.00%	

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Requisitions 2019-53 -- 2019-58

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratifications of Requisitions 2019-53-- 2019-58

2019-53	Foresberg Construction	$125,246.67	
2019-54	Foresberg Construction	$233,209.68	
2019-55	County Materials Corp	$8,521.40	
2019-56	Ferguson Waterworks	$16, 708.61	
2019-57	County Materials	$25,064.60	
2019-58	County Materials	$7,268.08	

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackbum Creek Connnunity Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March l, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of February I, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-53

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950

$125,246.67

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs ofissuance, if applicable):

Grand Palm, Phase 1B(a) Application No. 3 (See attached Invoice). This Application for Payment is approved based on a site and observation of work.

The undersigned hereby certifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incuned in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].
The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof

Blackburn Creek Community Development District
The undersigned hereby further certifies that such requisition contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs oflssuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the  invoice(s)  from the vendor of the  property acquired  or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT
By	ez;;	
Authorized Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

w tm1{

If this requisition is for a disbursement from other than Costs ofissuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) thereport of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof

Con:mlting Engineer

CONTRACTOR'S APPLICATION FOR PAYMENT

REQUEST NO.

3

PROJECT	Grand Palm Phase !Ba (CDD Portion)

ENGINEER	Kimley-Horn and Associates, Inc.

NTPDATE
Contract Time SUBSTANTIAL FINAL

November 26, 2018
409 Days (270+141)
January 9, 2020
February 6, 2020

OWNER

Blackburn Creek CDD
5800 Lakewood Ranch Boulevard Sarasota, FL 34240

CONTRACTOR

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950

FOR WORK COMPLETED FROM	10/1/2019	TO	10/31/2019

CONTRACT  PAYMENT SUMMARY

Original Contract Amount (CHANGE ORDER #6)		755,053.00	
Change Orders:			
Change Orde
Number	Date Aooroved

Subtotals
Net Change Order Subtotal (Additive less Deductive Current Contract Amount (Original Amount+ CO's)	r Summary
Additive
-
-
-
-
-
)

Previous Status	
Deductive

-
-
755,053.00
Current Status	
Value of Work in Place		371,57 1.00	72%	547,396.00		
Value of Material Purchased by Owner		87,498.72		131,485.11		
Total Earned (% & $)	38%	284,072.28	55%	415,9!0,89		
Retainage (% & $)	5%	14,203.61	5%	20,795.54		
Net Earned (Total earned minus retainage)		269,868.67		395,115.34	395,115.34	
Total Previous Estimates					269,868.67	
AMOUNT DUE THIS PERIOD					125,246.67	

CERTIFICATION   OFCONTRACTOR

CONTRACTOR

The undersigned Contractor hereby swears under penalty of perjury that (I ) all previous progress payments received from the Owner on account of Work performed under the Contract referred to above have been applied by the undersigned todischarge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered I through 2 inclusive; and (2) all materials and equipment inco rporated in said Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances; and (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective asthat term is defined in the Contract Documents.

Notary Public, State of Florida

My Commission  expires Augu:sµ,· -VIIAIA.IY>A/YYV\i"'JV..,,.,,.	('
Sworn and subscribed to me tuc' 1':.,'J'	Notary Public State of Florida

My Cornmlulon GG 008306

1st day ofNovember AD 2019l   -·'f) Ashly Wesler

Punta Gorda, Florida 33950 Phone (941) 637-8500
Fax (941) 639-I073

(STAMP I SEAL)

lff\: _

EwpJru 08/ 312020

Payment of the above AMOUNT DUE THIS APPLICATION is recommended.

Engineer Owner

DA

,,lli.LJ_
I	I

Project:	Grand  Palm  Phase !Ba  (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	3
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	10/1/2019
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	10/31/2019
PREVIOUS WORK	WORK THIS PERIOD	WORK TO DATE	PERCENT

 	1,760.00	32.ol	1,760.00 
2	910	24"RCP	611	LF	65.00 i	39,715.00	611.0I	39,715.00
3	910	30" RCP	173	LF	84.00	14,532.00	173.0	14,532.00
4	910	36" RCP	472	LF	116.00	54,752.00	472.0	54,752.00
5	910	Grated Swale Inlet	I	EA	3,400.00	3,400.00	1.0	3,400.00
6	910	Type "M" Inlet 36" x 48" (inside size)	5	EA	4,200.00	21,000.00	5.0	21,000.00
7	910	Type "M" Inlet 42" x 60" (inside size)	2	EA	6,900.00	13,800.00	2.0	13,800.00
8	910	24" Flared End Section	2 I EA	4,100.00	8,200.00	2.0	8,200.00
9	910	30" Flared End Section	I	EA	4,500.00	4,500.00	1.0	4,500.00
IO	910	36" Flared End Section	3	EA	5,800.00	17,400.00	3.0	17,400.00
11	910	Small Control Structure	I	I	EA	5,600.00	5,600.00	1.0	5,600.00
910	Modified Type "F" curb (Islands)	I	220	LF	16.20	3,564.00	0.0	-

0.00	-	173.001	14,532.00  '	100.00%
0.00	-	472.00[	54,752.00 !	100.00%

'

0.00	-	1.00!	3,400.00 I	100.00%
0.00	-	5.001	21,000.00	100.00%
0.00	.	-	I	2.00	13,800.00 ,	100.00%
0.00	-	2.00	8,200.00 I	100.00%
0.00	-	1.00	4,500.00	100.00o/o
0.00	-	3.00	17,400.00	100.00o/o
0.00	-	1.00	5,600.00.	100.00%
0.00	-	0.00	-	0.00%

910	Type "M" curb, includes all transitions
'

4,420	LF	10.80	47,736.00	0.0	-	0.00	-	0.00	-	0.00%

17	910	Curb ramp	i	4	EA	780.00	3,120.00	0.0	-	I	0.00	-	0.00	-	0.00%

I	960	Manholes 0' - 6'	4	EA I	5,600.00	22,400.00	0.0	-	'i

4.00	22,400.00	4.00	22,400.00	100.00%

2	960	Manholes 6' - 8'	4	EA	6,200.00	24,800.00	2.0	12,400.00 I	2.00	12,400.00	4.00	24,800.00	100.00%1
3	960	Manholes 10' - 12'	2	EA	7,800.00	15,600.00	2.0	15,600.00	0.00	-	2.00	15,600.00	100.00%
4	960	8" PVC (SDR 26) Gravity Sewer O' - 6'	788	LF	34.00	26,792.00	0.0	-	788.00	26,792.00	788.00	26,792.00	100.00%
5	960	8" PVC (SDR 26) Gravity Sewer 6' - 8'	553	LF	52.00	28,756.00	260.0	13,520.00	293.00	15,236.00	553.00	28,756.00	100.00%
6	960	8" PVC (SDR 26) Gravity Sewer 8' - !0'	280	LF	70.00	19,600.00	280.0	19,600.00	0.00	-	280.00	19,600.00	100.00%
7	I	960	u	y....,	-,	382	LF	87.00	33,234.00	382.0	33,234.00	0.00	-	382.00	33,234.00	100.00%

8	960

'"'
Single

Sewer Service	4	LF	1,500.00	6,000.00	0.0	-	0.00	-	0.00	-	0.00%

9	960	Double sewer service	26	EA	1,500.00	39,000.00	0.0	-	0.00'	-	0.00	-	0.00%
IO	960	Connection to existing gravity sewer	I	EA	6,600.00	6,600.00	1.0	6,600.00	0.00	-	1.00	6,600.00 I	100.00%
II	960	Open Cut Restoration and MOT	I	LS	11,300.00	11,300.00	0.5	5,650.00	0.25	2,825.00	0.75.	8,475.00	75.00%
12	960	Testing of gravity sewer	2,003	LF	4.00	8,012.00	0.0	-	0.00	-	0.001	-	0.00%
74"  PVC DR-18, C900 Water Main	520	LF	24.00	12,480.00	O.O!	-	520.00	12,480.00	520.001	12,480.00 !	100.00%
2	1010  i8" PVC DR-18, C900 Water Main	1,960	LF	28.00	54,880.00	156.0	4,368.00	1804.00	50,512.00	1960.00	54,880.00	100.00%
3	1010   !4" Gate valve and valve box	2	EA	1,500.00	3,000.00	0.0	-	2.00	3,000.00	2.00	3,000.00	100.00%
4	1010  18" Gate valve and valve box	4	EA	2,000.00	8,000.00	0.0	-	4.00	8,000.00	4.00	8,000.00	100.00%
5	1010	8"x8" Tapping Sleeve and Valve	2 i        EA	7,800.00	15,600.00	2.0	15,600.00 I	0.00	-	2.00	15,600.00	100.00%

6	1010	Blowoff Assembly	I:   EA	1,200.00	1,200.00	0.0	-
7	1010	HG-2 Automatic Flushing Device	I	I	EA	7,400.00	7,400.00	0.0	-	'

0.00	-	0.00	-	0.00%
0.00	-	0.00	-	O.OO¾i

8	1010	Fire Hydrant Assembly	2	EA	6,000.00	12,000.00	0.0	-	2.00,	12,000.00	2.00	12,000.00	100.00%1
9	1010	Single water service (Short)	34	EA	1,000.00	34,000.oo I	0.0	-	o.oo:	-	0.00	-	0.00%
IO	1010	Single water service (Long)	22	EA	1,200.00	26,400.00 I	0.0	-	0.001	-	0.00'	-	0.00%
II	1010	Tie-in to existing Water Main	2	EA	2,500.00	5,000.00 I	0.0	-	1.00	2,500.00 I	1.001	2,500.00 I	50.00%
12	1010	Pressure testing of main	2,480	LF	2.10	5,208.00	0.0	-	0.00	-	0.00	-	I	0.00%
13	1010  ,Chlorination and bacteriological	 	2,480	LF	1.90 :	4,712.00	0.01		-	0.001	-	i	0.00,	-	0.00%

Project: Owner: Engineer:

ITEM NO.
II

3
4
5

I

DRAINAGE SANJTARY SEWER	$	239,079.00
$	242,094.00	$	184,659.00
$	106,604.00	$
$	79,653.00	$	184,659.00
$	186,257.00	77.24%
76.94%	
WATER DISTRIBUTION	$	189,880.00	$	19,968.00	$	88,492.00	$	108,460.00	57.12%	
MISCELLANEOUS	$	84,000.00	$	60,340.00	$	7,680.00	$	68,020.00	80.98%1	
TOTAL	$	755,053.00	$	371,571.00	$	175,825.00	$	547,396.00	72.50%	

Grand Palm Phase lBa (CDD Portion) Blackbum Creek CDD
Kimley-Horn and Associates, Inc.

CODES

1260	Forsberg 645
Punta	Construct ChBrlotte St Gorda, FL

PREVI	ion, Inc. reet 33950

OUS WORK	

WORK	

THIS PERIOD	Pay Reques
For work To:

WORK	t No.
from:

TO DATE	3
10/1/2019
10/31/2019

PERCENT COMPLETE
%	
260	IConstruction stakeout	I iLS	25,600.00	25,600.00	0.4	10,240.00	0.30	7,680.00	0.70	17,920.00		70.00%	
260	Record drawings/ As-Built Survey	l ILS	8,300.00	8,300.00	0.0		0.00		0.00			0.00%	
510	IMobilization	I ;Ls	50,000.00	50,000.00	1.0	50,000.00	0.00		1.00	so,000.00		100.00%	
			755,053.00		371,571.00		175,825.00		547,396.00		72.50%	
ummary of Work Classifications
PHASE3C	

Project:    Grand Palm Phase !Ba (CDD Portion)	Forsberg Co truction, Inc.	Pay Request No.	3
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	10/1/2019
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	10/31/2019	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

UNIT	MATERIAL
UNIT PRICE	PURCHASE ORDER
TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT
COMPLETE
%	
	I.a DRAINAGE (excludes FDOT final pipe inspection)	I	I		I		I	
I	18" RCP	32	LF	16.05 i	513.60 ;	32.00	513.60		0.00i	-	32.00	513.60	i	100.00%	
2	24" RCP	611	LF	24.65 !	15,061.15 .	611.00	I5,061.15		0.00'	-	611.00	15,061.15 i	100.00%	
3	30" RCP	173	LF	35.33	6,112.09 I	173.00	6,112.09	0.00	-	173.00	6,112.09	100.00%	
4	36" RCP	472	LF	48.53	22,906.16	472.00	22,906.16		0.00·	-	472.00	22,906.16	I	100.00%	
5	Grated Swale Inlet	I	EA	650.54	650.54	1.00	650.54		o.oo:	-	I	1.00	650.54	!	100.00%	
6	Tvne "M" Inlet 36" x 48" (inside size)	5	EA	1,526.64	7,633.20	5.00		7,633.20 I	o.oo;	-	5.00	7,633.20 :	100.00%	
7	Type "M" Inlet 42" x 60" (inside size)	2	EA	1,526.64	3,053.28	2.00		3,053.28 i	0.00!	-	2.00	3,053.28	!	100.00%	
8	24" Flared End Section	2	EA	1,012.00	2,024.00	2.00		2,024.00 !	0.00!	-	2.00	2,024.00 i	100.00%	
9	30" Flared End Section	I	EA	1,315.40	1,315.40	1.00		1,315.40 I	o.oo:	-	1.00	1,315.40	I	100.00%	
10	36" Flared End Section	3	EA	1,562.00	4,686.00	3.00	4,686.oo I	0.00		-	3.00	4,686.00	100.00%	
11	Small Control Structure	I	EA	1,847.74	1,847.74	1.00	1,847.74 !	0.00		-	1.00	1,847.74	100.00%	
	Lb SANITARY SEWER							:			
I	Manholes O' - 6'	4	EA	1,537.21	6,148.84	0.00		-	• !	4.00		6,148.84 :	4.00	6,148.84	100.00%	
2	Manholes 6' - 8'	4	EA	1,754.51	7,018.04	2.00		3,509.02 1	2.00		3,509.02 i	4.00	7,018.04	100.00%	
3	Manholes 10' - 12'	2	EA	2,249.77	4,499.54	2.00	4,499.54	0.00	-	2.00	4,499.54	100.00%	
4	8" PVC (SDR 26) Gravity Sewer O' - 6'	788	LF	4.06	3,199.28	0.00	-	788.00		3,199.28 I	788.00	3,199.28	100.00%	
5	8" PVC (SDR 26) Gravity Sewer 6' - 8'	553	LF	4.06	2,245.18	260.00	1,055.60	293.00		1,189.58 I	553.00	2,245.18	100.00%	
6	8" PVC (SDR 26) Gravity Sewer 8' - 10'	280	LF	4.06	1,136.80	280.00	1,136.80	0.00	-	280.00	1,136.80	100.00%	
7	8" PVC (SDR 26) Gravity Sewer IO' - 12'	382	LF	4.06	1,550.92	382.00	1,550.92	0.00	-	382.00	1,550.92	100.00%	
8	Single Sewer Service	4	LF	273.52	1,094.08	0.00	-	0.00	-	0.00	-	0.00%	
9	Double sewer service	26	EA	314.29	8,171.54	O.OOi	-	0.00	-	0.00	-	0.00%	
	Le WATERDISTRIBUTION											
I	4" PVC DR-18, C900 Water Main	520	LF	3.19	1,658.80	0.00	-	520.00	1,658.80	520.00	1,658.80	100.00%	
2	8" PVC DR-18, C900 Water Main	1,960	LF	9.30	18,228.00	156.00	1,450.80	1804.00	16,777.20	1960.00	18,228.00	100.00%	
3	4" Gate valve and valve box	2	EA	484.41	968.82	0.00	-	2.00	968.82		2.00	968.82	100.00%	
4	!8" Gate valve and valve box	4	EA	847.30	3,389.20	0.00	-	4.00	3,389.20		4.00	3,389.20	100.00%	
5	i8"x8" Tapping Sleeve and Valve	2	EA	1,770.06	3,540.12	2.00	3,540.12	0.00	-		2.00	3,540.12	100.00%	
8	IFire Hydrant Assembly	2	EA	2,274.03	4,548.06	0.00	-	2.00	4,548.06		2.00	4,548.06	100.00%	
9	iSingle water service (Short)	34	EA	319.96	10,878.64	0.00	-	0.00	-	0.00	-	0.00%	
10	Single water service (Long)	22	EA	365.73	8,046.06	0.00	-	0.00	-	0.00	-	0.00%	
11	Tie-in to existing Water Main	2	EA	107.80	215.60	0.00	-	1.001	107.80	1.00	107.80	!	50.00%	
TOTAL		$	152,340.68 I	$	82,545.96	$	41,496.60	$	124,042.56 I	81.42%	

Ferguson Waterworks
Cast Systems County Materials 6% State Sales Tax				Summary

$	68,871.10
$	30,851.18
$	52,618.40
$	9,140.44	

$	8,734.24
$	21,193.32
$	52,618.40
$	4,952.76		

$	31,838.74
$	9,657.86
$	-
$	2,489.80		

$	40,572.98
$	30,851.18
$	52,618.40
$	7,442.55		

58.91%
100.00%
100.00%
81.42%	

Project:    Grand Palm Phase lBa (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	3
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	10/1/2019
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	10/31/2019	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

IUNIT	MATERIAL UNIT
PRICE	PURCHASE ORDER
TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
	TOTAL				$	161,481.12	$	87,498.72	$	43,986.40	$	131,485.11	81.42%	

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the tenns of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of February I, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized te1ms used herein shall have the meaning ascribed to such tenn in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-54

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950

Amount Payable:	$233,209.68

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Grand Palm, Phase 2A(d) Application No. 2 (See attached Invoice). This Application for Payment is approved based on a site and observation of work.

The undersigned hereby certifies that [obligations in the stated amount set f01th  above  have been incurred by the District, that each disbursement set forth above is a  proper  charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 20 I9 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account  that  has  not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or clainI affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released sinlultaneously with the payment hereof

Blackburn Creek Community Development District
The undersigned hereby further certifies that such requisition contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By    :
Aut		- 

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs ofl ssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indent ure, as such report shall have been amended or modified on the date hereof.

/

��
Consulting Engineer

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase 2Ad (CDDPortion)

ENGINEER	Kimley-Horn and Associates, Inc. OWNER	Blackburn Creek CDD
5800 Lakewood Ranch Boulevard Sarasota, FL 34240	REQUEST NO

NTPDATE
Contract Tim SUBSTANTI FINAL

CONTRACT	.

e AL

OR	2

March 21, 2019
360 Days
March 15, 2020
April 12, 2020

Forsberg Construction, Inc .
645 Charlotte Street Punta Gorda, FL 33950	
FOR WORK COMPLETED FROM	10/1/2019	TO	10/31/2019	

CONTRACT  PAYMENT SUMMARY

Original Contract Amount Change Orders:	1,317,081.00	
Change Order Summary		
Number	Date Approved	Additive	Deductive		
		.			
		-			
		-			
		-			
Sub totals	-	.		
Net Change Order Subtotal (Additive less Deductive)	.	
Current Contract Amount (Original Amount+ CO's)	1,317,081.00	

Value of Work in Place
Value of Material Purchased by Owner Total Earned(%& $)
Retainage (%& $)	Previous Status	Current Status		

4%
5%	55,920.00
343.28
55,576.72
2,778.84	28%

23%
5%	364,862.00
63,801.4 I
301,060.59
15,053.03		
Net Earned (Total earned minus retainage)		52,797.88		286,007.56	286,007 .56	
Total Previous Estimates					52,797.88	
AMOUNT DUE THIS PERIOD					233,209.68	

CERTIFICATION   OF CONTRACTOR

The undersigned Cont ractor hereby swears under penalty of perjury that (I) all previous progress payments received from the Owner on account of Work performed under the Contract referred to above have been applied by the undersigned todischarge in full all obligations of undersigned incu rred in connection with Work covered by prior Applications for Payment numbered I through I inclusive; and (2) all materials and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances; and (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective as that term is defined in theCo11_tract Document.s Notary Public, State of Florida	 My Commission expires August .::K.7'v...,,.V\-'VV..,,.,,N"V'.,.,..,NYV"'J Punta Gorda, Florida 33950
Sworn and subscribed to me this	Phone (94 I) 637-8500

Isl day of November AD 2019	Fax (941) 639-1073 (STAMP/ SEAL)

Engineer

Payment of the above AMOUNT DUE THIS APPLICATION is recommende.d

'rt:L(h

DATE
  	ill_\o\\<\	

Owner	tu	 	k(6 /11

Project:	Grand  Palm  Phase  2Ad (CDD Portion)	Forsber.g Construction, Inc.	Pay Request No.	2
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	10/1/2019

-	

Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	10/31/2019
PREVIOUS WORK	WORK THIS PERIOD	WORK TO DATE		PERCENT CONTRACT   I			COMPLETE
TOTAL

11,935,00
49,985.00	0.0	-	0.00	-	0.00	-	0.00%
3	910	30"RCP	741	LF	84.00	62,244.00	0.0	-	0.00	-	0.00	-	0.00%
4	910	36"RCP	192	LF	116.00	22,272.00	0.0	-	0.00	-	0.00	-	0.00%
5	910	54"RCP	400	LF	262.00	J04,800.00	0.0	-	400.00	J04,800.00	400.00	104,800.00	J00.00%1
6	!	910	Grated Swale Inlet	2	EA	3,400.00	6,800.00 i	0.0	-	0.00	-	0.00	-	0.00%
7	9JO	Type "F" Inlet 36" x 48" (inside size)	2	EA	4,200.00	8,400.00 I	0.0	-	0.00	-	0.00	-	0.00%
8	9JO	Type "M" Inlet 36" x 48" (inside size)	11	EA	4,200.00	46,200.00:	0.0	-	0.00;	-	0.00	-	0.00%
9	9JO	Type "M" Inlet 42" x 60" (inside size)	I	EA	6,900.00	6,900.00	0.0	-	0.00	-	0.00	-	0.00%
10	9JO	24" Flared End Section	3	EA	4,J00.00  ,	12,300.00	0.0	-	0.00	-	0.00	-	 	0.00% 

II	910	30" Flared End Section	2    EA	4,500.00	9,000.00	o.o:	-	0.00	-
12	9JO	36" Flared End Section	I	EA	5,800.00	5,800.00	O.Oj	-	0.00	-	'

0.00	-
o.oo:	-

0.00%
0.00%

13	910	54" Flared End Section	I I         EA	9,200.00	9,200.00	0.0	-	1.00	9,200.00 '	1.00'	9,200.00 :	J00.00%1
14	910	Storm Junction Box	4 I          EA	7,200.00	28,800.00	0.0	-	0.00	-	o.oo,	-	'	0.00%
15	910	Medium Control Structure	1 [   EA	J0,000.00	10,000.00	0.0	-	1.00	J0,000.00 !	1.00•	J0,000.00 '	J00.00%
16	9JO	Rip-Rap for Bubbler Structures	93 i SY	J00.00	9,300.00	0.0	-	0.00	-	0.00	-	'	0.00%
17	9JO	Connect to Existing Storm Structure	3 i  EA	5,000.00	15,000.00	0.0	-	0.00	-	0.00	-	I	0.00%
18	9JO	Remove Ex Storm Pipe & Structures	I	EA	3,500.00	3,500.00	1.0	3,500.00	0.00	-	1.00	3,500.00	0.00%
22	910	Modified Type "F" curb	1,180	LF'	10.80	12,744.00	0.0	-	0.00	-	0.00	-	0.00%

23	9JO	Type "M" curb	'	6,4JO	LF,	10.80	69,228.00	0.0

-	I	0.00

-	0.00

-	0.00%

24	910	Modified Type "F" curb (Islands)	240	LF  ,	16.20	3,888.00	0.0	-	0.00	-	0.00	-	0.00%'
25	910	Valley Crossing curb	190	LF I	43.20	8,208.00	0.0	-	0.00	-	0.00	-	0.00%
26	910	Curb ramp	!	6	EA I	780.00	4,680.00 I	0.0	-	0.00	-	0.00

960	Manholes 0' - 6'	5	EA-	0.00
2	960	Manholes 6' - 8'	3    EA	6,200.00	18,600.00 !	0.0	-	0.00'	-	o.oo!	-	!	0.00%
3	960	Manholes 8' - 1O'	4	EA	7,000.00 i	28,000.00	0.0	-	4.001	28,000.00	4.ool	28,000.00 I	J00.00%1
4	960	Manholes IO' - 12'	I	EA	7,800.00 :	7,800.00	o.o:	-	0.00	-	0.001	-	I	0.00%
5	960	8" PVC (SDR 26) Gravity Sewer 0' - 6'	568	LF	34.00	19,312.00	0.0	-	0.00	-	0.00'	-	0.00%
6	960	8" PVC (SDR 26) Gravity Sewer 6' - 8'	1,117	LF	52.00	58,084.00	0.0	-	399.00	20,748.00	399.001	20,748.00	35.72%
7	960	8" PVC (SDR 26) Gravity Sewer 8' - 10'	377	LF	70.00	26,390.00	0.0	-	308.00	21,560.00	308.00	21,560.00	81.70%

8	960	'."

-	•- J ~•-•n.J '-	873 I        LF	87.00

75,951.00

0.0	-	'	522.00	45,414.00	522.00	45,414.00	59.79%-

9	960	S'"ingle sewer service	16:    EA	1,500.00

24,000.00

0.0	-	0.00	-	0.00	-	0.00%

IO	960	IDouble sewer service	27:   EA	1,500.00	40,500.00	0.0	-

'

II	960	I Connection to existing gravity sewer	I	2	EA 1	6,600.00	13,200.00	0.0	-	I
LF	40.00
JOJO	6"  PVC DR-18, C900 Water Main	I	480	LF	,

0.00	-	0.00	-	0.00%
1.00	_6,_600.00	1.00	6,600.00	50.00%

2	JOJO	8"  PVC DR-18, C900 Water Main	4,3JO	LF	28.00	120,680.00	0.0i	-	0.00	-	I	0.00i
3	1010	6" Gate valve and valve box	2	EA	1,800.00 i	3,600.00	I.Oi	1,800.00	0.00	-	1.00,	1,800.00;
4	JOJO	8" Gate valve and valve box	16	EA	2,000.00 i	32,000.00	0.0	-	0.00	-	o.ooi	-	I

50.00%1
0.00o/

Project: Owner: Engineer:

Grand Palm Phase 2Ad (CDD Portion)
Blackburn Creek CDD
Kimley-Horn and Associates, Inc.

Forsberg Construction, Inc.
645 Charlotte Street Punta Gorda, FL 33950

PREVIOUS WORK	WORK THIS PERIOD

Pay Request No. For work from:
To:

WORK TO DATE

2
10/1/2019
10/31/2019

-

PERCENT COMPLETE

QTY	VALUE
v(\      .v(\      ,i	-
'	.V.,.V'	-

QTY
O.OOj
0.00

VALUE

2:!r....
0.001
------ 0.00'
-·

VALUE

%
I	0.00%
0.00%

0.0'	-

0.00

 	0.00	

0.00%1

8		1010	Temporary Blow-off Assembly	1 I	EA I	1,200.00 j	1,200.00	
9		1,v01,v0	Tie-intoexistingWaterMain	3	EA!	2,500.00	I	7,500.00	
IO		.  10-·10-	pitch Crossing w/Concrete Cap	1	EA i	6,600.00 I	6,600.00	
11		1010	IPressuretestingofmain	4,790 I	LF	2.10 I	I0,_059.00	

.0..0:	-

0.00

 	0.00 

 	 	0.00%

I	u.ul

-	0.00I	0.00

0.00%

- 0

_--"--'-+_-

-	I	0-.-00
-	0.00

_c_=c.c...+-----'=+	+-

n-nvnv
0.00

0v,0v0%
0.00%
0.00%

.. 

1nnnn  I          100.00%
v.v +-

=+---------l	57,500.00

 	Y--/,.'.-)-U-U- .-UU	 100.00%

4	260	Construction stakeout	1 LS	25,600.00	25,600.00	0.0	----e-- 0.20	5,120 00 !		0.201	
											
5	260	Record drawings/ As-Built Survey	1 LS	8,300.00	8,300.00	0.01	0.00		·		

-s· 120.00	 	20.00%
- '	0.00%

Mobilization/General Conditions	1 ILS	50,000.00	50,000.00 I	1.0:	50,000.00	0.001	l	50,000.00 ;	100.00%1	
TOTAL		1,317,081.00		55,920.00		 	308,942.00 	 	  364,862.00	 	27.70%	
Summary of Work Classifications
PHASE3C	

ITEM
  NO.	CODES	DESCRIPTION	I
OF WORK	I	I
_QUAN iuNIT	UNIT	I
PRICE	
CONTRACT TOTAL		
    5	1010 	Fire Hydrant Assembly	41 EA I	6,000.00	24,000.00 i		
6	1010	Sini.Ie water service (Short)
     7	1010  Sin e water service (Long)
i

l------'-- =.	==.._._.=====-------....c...;=
2	Material Price Increases for 2019

6	510

260

910

1010

TOTAL	42	EA	1,000.00	42,000.00
28  I  EA  I	1,200.00 :	33,600.00

----'--'-=c+	'1-"oo"'.""'ooc..+-
1   LS	57,500.00	57,500.00:		

510

960

1260

$	112,720.00	79.66%

DRAINAGE	$	521,184.00	$	3,500.00	$	124,000.00	$	127,500.00	24.46%	
SANITARY SEWER	$	351,577.00	$	$	122,322.00	$	122,322.00	34.79%	
WATER DISTRIBUTION	$	302,820.00	$	2,320.00	$	$	2,320.00	0.77%	

$	33,900.00	$	$	5,120.00	$	5,120.00	15.10%	
$	107,500.00	$	50,000.00	$	57,500.00	$	107,500.00	100.00%	
$	521,184.00	$	3,500.00	$	124,000.00	$	127,500.00	24.46%	
$	351,577.00	$	$	122,322.00	$	122,322.00	34.79%	
$	302,820.00	$	2,320.00	$	$	2,320.00	0.77%	
$	100.00	$	100.00	$	$	100.00	100.00%	
$ 1,317,081.00	$	55,920.00	$	308,942.00	$	364,862.00	27.70%	

MISCELLANEOUS	$	141,500.00	$	50,100.00	$	62.620.00	
TOTAL	$ 1,317,081.00	$	55,920.00	$	308,942.00	

Summary of Accounting Codes	

$	364,862.00	27.70%

Project: Grand Palm Phase 2Ad (CDD Portion)
Owner: Blackburn Creek CDD
Engineer: Kimley-Horn and Associates, Inc.

Forsberg Construction, Inc.
645 Charlotte Street Punta Gorda, FL 33950

Pay Request No. For work from: To:

2
10/1/2019
10/31/2019

ITEM NO.

DESCRIPTION OF WORK

_QUAN iuNIT

MATERIAL UNIT PRICE

PURCHASE ORDER TOTAL

PREVIOUS WORK

QTY	VALUE

WORK THIS PERIOD

_QTY	VALUE

WORK TO DATE

_QTY	VALUE

PERCENT COMPLETE!
%

I.a DRAINAGE (excludes FDOT fimil_l)ipe inspection) '

1	i	I	I

18" RCP	.	.	,- iTif

13.62	2,955.54 I	0.00	-	0.oo.:

-	0.00	0.00¾I

i-----4-.	!  24" RCP	_'	769 j             LF	24.67	I8,971.23 .	0.00	-	0.00    -·   ..	-	I	0.00	0.00
3	30" RCP	I	741 ' LF	34.87	25,838.67	0.00	-	I	0.00.	-	!	0.00	------'- 0.00%
4	136" RCP	I	192  'LF	..	48.53	9,317.76	0.00	-	,	0.001	-	0.00	_ 	Q.00%
!54" RCP	-·	I	400    LF	98.03 ;	39,212.00 •	0.00	-	400.00I  ...   39,212.00	400.00	39,212.00 !	IO_()"_00%
6	Grated Swale Inlet	I	2    EA	1,044.30  !	2,088.60  !	0.001	-	0.001	-	0.00	0.00%
1	7	Type "F" Inlet 36" x 48" (inside size)	I	2 ,  EA	1,350.11 I	2,700.22	0.001	-	0.00 ,···	-	0.00	_	0.00%
'	8	Type "M" Inlet 36" x 48" (inside size)	I	11 i  EA	1,407.64	15,484.04	0.00!	-	0.00	.	-  ,	0.00	_	0.00%1
9	Type "M" Inlet 42" x 60" (inside size)	I	1 1  EA	1,407.64	1,407.64	0.001	-	0.00	-	0.00	0.00%
IO	24" Flared End Section	,	3    I  EA	1,012.00	3,036.00	0.00I	...	-	I	0.00	.-.	-	0.00	0.00%
30" Flared End Section	2 !     EA	1,315.40	2,630.80	0.00'	-	1	0.00	-	i	0.001	·------'	0.00%

1

-·12	36" Flared End Section	-	I  !      EA  !	1,562.00.	1,562.00	0.00	-	0.00		-	I	o:oo,	-----'- . ·o:oci¾ 13	54" Flared End Section		I  I  EA  ,	4,086.70	4,086.70	0.00	-	1.00	4,086.70  '	1.00		4,086.70	l00.00%
14	iStormJunctionBox	4    EA	1,470.54 I	5,882.16	0.00,	-	0.00!	-	0.00	-	0.00%
15	!Medium Control Structure	1 ,  EA	2,881.57 I	2,881.57	0.00I	-	1.00	2,881.57 ·-·	1.00	2,881.57 1	l00.00%

Lb SANITARY SEWER	_.	1	••••       !	i

        I	.	 	j   	

1	1        Manholes 0' - 6'	5,   EA	 1,584.28 1	7,921.40 !	0.00	-	I	0.00	-	!	0.00!	_	0.00%1
2	Manholes 6' - 8'	3    EA	1,834.15,	5,502.45  ,	0.00	-	0.00	-	!	0.00	0.00%

--- -	-

,,...	'	---

3	Manholes 8' -10'	4    EA	2,177.11	8,708.44	0.00	-	!	4.00	_  8,708.44 i	4.00	8,708.44  '	100.00o/o

t=.§	 		 	  	 		 	

4	,Manholes 10' - 12'	1   EA  1	2,550.72	2,550.72	0.00	-	0.00	_	-	0.00	0.00%
5	18" PVC (SDR 26) Gravity Sewer 0' - 6'	568    LF  !	4.05	2,300.40  ,	0.00	-	0.00,	-	0.00	0.00%
18" PVC (SOR 26) Gravity Sewer6' - 8'	-· I,117    LF	4.05	4,523.85 !	0.00!	399.001	1,615_.95	399.00	1,615.95 !	35.72%
7	8" PVC (SOR 26) Gravity Sewer 8' - 10'	377 · LF	4.05 1	1,526.85 I	0.001	308.001	1,247.40	308.00	1,247.40 '	81.70%
8	8" PVC (SOR 26) Gravity Sewer 10' - 12''	873  ;  LF	4.05  I	3,535.65	0.00,	522.00i	2,114.10	522.00	2,114.10	59.79%
9	Singlesewerservice	..	16 I  EA  I	273.52  I	4,376.32	o.oo•	()_()Qi	0.00	0.00%
!Q_   Double sewer service	_	27 I  EA_	314.21	8,483.67	0.00'	0.00	0.00	 	0.00% Le WATER DISTRIBUTION

1	6"PVCDR-18,C900WaterMain	480   LF	2.16	1,036.80	20.00	43.20	0.00	·--

20.00

43.20 j

_±.17%

2	8" PVC DR-18, C900 Water Main	4,310    LF	7.09	30,557.90	0.00 I	0.00	0.00i
3	16"Gatevalveandvalvebox	2    EA	280.65	561.30	1.00	280.65	0.00	LOOI
4	18"Gatevalveandvalvebox	16    EA	370.70	5,931.20 !	0.00!	0.00	0.00
5	1Fire Hydrant Assembly	4  !    EA	2,312.63	9,250.52,	0.001	i	0.00 	0.00
6	ISinglewaterservice(Short)	42 I   EA	331.88	13,938.96,	0.00	i	0.00	-	0.00

I·

7	Single water service (Long)	28 ' EA	368.67	10,322.76	0.00	0.00,	0.00
9	!Tie-in to existing Water Main	3 'EA	133.80	401.40  j	0.00I	0.00	0.00
TOTAL	$	259,485.52  I	$	323.85  i	$	59,866.16 I	$

Summary

0.00%
280.65	50.00%1
0.00%
0.00%
1
0.00%
0.00%

1

-  .   j	0.00%
60,190.01	23.20%

Ferguson Waterworks	$

96,747.58	$	323.85	$	4,977.45	$	5,301.30	5.48%

Project: Grand Palm Phase 2Ad (CDD Portion)
Owner: Blackburn Creek CDD
Engineer: Kimley-Horn and Associates, Inc.				Forsberg Construction, Inc.
645 Charlotte Street Punta Gorda, FL 33950		Pay Request No. For work from: To:	2
10/1/2019
10/31/2019	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

JNIT	MATERIAL UNIT
PRICE	PURCHASE
ORDER TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT
COMPLETE
%	
	Cast Systems County Materials 6% State Sales Tax				$	55.127.24
$	107,610.70
$	15.569.13	$	-
$	-
$	19.43	$	11.590.01
$	43,298.70
$	3.591.97	$	11.590.01
$	43.298.70
$	3,611.40	21.02%
40.24%
23.20%	
	TOTAL				$	275,054.65	$	343.28	$	63,458.13	$	63,801.41	23.20%	

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March l, 2013 (the "Master Indenture"), as amended and supplemented by the Folllth Supplemental Trust Indenture from the District to the Trustee, dated as of February l, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shaJI have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-55

County Materials Corp.
P.O. Box435 Astatula, FL 34705

$8,521.40

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Direct purchase of material for construction of Grand Palm, Phase 2A(d). Purchase Order # 190402; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

The undersigned hereby further ce1tifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such reqms1t10n contains no  item representing payment on account of any retained percentage which the District  is at  the date of such certificate entitled to retain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the  vendor of the  prope1ty acquired  or the services rendered with respect to which disbursement is hereby requested.

By Gl:z	

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Authorized Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs ofl ssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or constmction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indentur e, as such report shall have been amended or modified on the date hereof

2	.l	.

�	�
Consulting Engineer

cf'

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 2A(d)

    Invoice #		Amount	 149188-09	$3,921.20
   149188-11	$4,600.20	
Sub-Total	$8,521.40

COUNT Y

SHIPPED	INVOICE DA TE	I	ORDER NO.	
10/24/19	10/24/19	I	1491 88 -09	
I	P.O. NO.		I	PAGE#	
44	I ct	190402		I 1 of 1	

. (866) 343-8 488 Fax (352) 343-0471

NOV O 1 2019

INVOICE

M A TE RI A LS C O RPO RA T I O N

ASTATULA, FL 3470 5-0 435

REMIT TO:
PO BOX 38

CUST #:	3275	MARATHON, WI 54448 -0038
Grand Palm Phase 2AD
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION

OCT 3 0 2019

BILL TO:

645 CHARLOTTE STREET PUNTA GORDA FL 33950

LINEI
NO.	PRODUCT
AND DESCRIPTION	QTY .	I QT.Y I	UNIT PRICE	AMOUNT (NET)	
9	254380		v	40. 00 LFT	98. 03 v	3921. 20	
54" RCP CL3
10 254		
/	5. 00	EA	
0. 00	
0. 00	
54" RCCP GASKET HK	#839453				
Total	3921. 20
Invoice Total	3921. 20	

I	,SHIPPED	U/M

COUNTY

SHIPPED	INVOICE DATE	I	ORDER NO.	
10 /25/19	10 /25/1 9	I	149 188 -11	
I	P.O. NO.		I	PAGE #	
44	I ct	190402		I 1 of 1	

. (866) 343-8488 Fax (352) 343-0 471

NOV O 1 2019	INVOICE

M ATE RIA L S C O RP O RAT IO N

ASTATULA, FL 3 470 5-0 435

REMIT TO:
PO BOX 38

CUST #:	3275	MARATHON, WI 54448 -00 38
Grand Palm Phase 2AD
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

Bil l TO:

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORDA FL 33950

LINE NO.	I	PRODUCT
AND DESCRIPTION	I	QTY . SHIPPED	I	
QTY.
U/M	I	UNIT PRICE	I	AMOUNT
INET)	
5	230380s	72. 00	LF	34. 73 .,,,,-	2500. 56	
	30" RCP CL3 SMALL BELL				
6	230s	9. 00	EA	0. 00	0. 00	
	30" RCCP GASKET SMALL BELL #839230				
9	254380	/	8. oo	LFT	9 8 . 03	784. 24	
	54" RCP CL3				
10	254	1. 00	EA	0.00	0. 00	
	54"RCCP GASKET HK #839453				
12	230889s	. 00	EA	1315. 40 /	1315. 40	
	30" FLARED END SECTION GB SMALL BELL				
			Total	4600.20	
			Invoice Total	4600. 20	

PURCHASE ORDER No. 	/90402	

Blackburn Creek
Co1nmunity Develop1nent District
c/ o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 339 50
Phone: (94L) 637 -8500	Fax: (941) 639-1073
Underground Utility License #CUC055716 Visit Us at www.forsbergconsrruction.com

Vendor: County Materials Corporation

Address:   P.O. Box 435	

   Astatula, FL 34705	

Attention: Johnny Smith 941-915-3671

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: ObeNation Blvd off of Center Road Venice, Florida
Legal Desc.:   Sec  19&20,  Twp: 39S,	Range 20E	

County:  Sarasota      	  Payment Terms:  Net 30 days	                                    Vendor Phone: 866-343-8488
Vendor Fax:  352-343-0471	

Quantity	Unit	Description	Unit Price	Total Price	
						
184	+/-	LF	18"RCP	s	16.05		s	2,953.20	
776	+/-	LF	24" RCP	$	24.45		s	18,973 .20	
744	+/-	LF	30" RCP	s	34.73		s	25,839.12	
192	+/-	LF	36" RCP	s	48.53		$	9,317.76	
400	+/-	LF	54"RCP	s	98.03		$	39,212.00	
3	+/-	EA	24 " Flared End Section	s	1,012.00		s	3, 036.00	
2	+/-	EA	30 " Flared End Section	$	1,3 15.40		s	2,630.80	
I	+/-	EA	36• Flared End Section	s	1,562.00		s	, 1 562.00	
I	+/-	EA	54• Flared End Section	$	4,086.70		s	, 4 086 .70	

						
						
		Prices ar e good for duration of the project.				
						
		Project Duration : April I 5, 2019 - April I 5, 2020				
!	Total Project Subtotal	s	107,610.78	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ 1.0 % on 1st $5,000.00	tax exempt	
TOTAL	s	107,6 10.78	

Blackburn Creek COD Chairman

 	-
Authorized Agent /signa tur e}
! IMPORTANT !

Date

Page	 		of	2

,1SEESPECIAL PROVISIONS ABOVE

ADD ITION AL TERMSAND CONDITIONSON PAGE 2

TERMS AND  CONDITIONS
Alf material shall be as specified and warranted in accordance to the Project specifications, plans and addenda. Material shall be within accepted standards for workmanship and quality, and shall be satisfactory to meet approval of the Owner, Owner's representative and Purchase.r

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. Alf items supplied without prior approval, that do not meet Project requirements, will bereturned to Vendor, by Vendor, at no charge to Purchaser.

Time is of the essence.

Delivery of materials to be coordinated by Purchaser in ord er to accommodate unloading. Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the following work day to be unloaded. Purchaser will not beresponsible for any demurrage charge for such hold over.

Should the Vendor fail to provide material as scheduled by Purchaser and Vendor, the Purchaser, upon 3 day written notice to Vendor, shall have the right to procure said materials elsewhere without further responsibility to Vendor.

Quantities are approximate and subject to project requirements.

Vendor agrees to accept without charge to Purchaser, all extra, non-specialty materials in good condition which remain after completion of work and will issue full credit for same.

Vendor shall sign and return Purchase Order within 1O days of Purchase Order date. Purchaser will return an executed Purchase Order to Vendor.

To insure prompt payment, Purchase Order number must appear on all invoices and copies of signed delivery slips attached.

Neith er party will change, alter, nor substitute any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be ini tialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaser without receipt of a properly sign ed and acceptable Purchase Order.

Shipment of any materials, before signing this Purchase Order, will beconsidered an acceptance of this Purchase Ord er.

If Vendor fails to properly execute and return Purchase Order within 1O days, Purchaser may consider offer rejected.

I 5. This agreeme n t shall be governed by the laws of the Stat e of Florida with venue in Charlotte Coun ty, Florida.

16. The authorized agent signing this Purchase Order for the Vendor must be duly authorized to do so on behalf of the Vendor or on behalf of any such disclosed principal.

17.

18 .

In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full force and effect.

This Purchase Order is the only binding contract betw een Purchaser and Vendor for this project and the work

r

described. This Purchase Order replaces all previous contracts and agreements,w heth  er written or  verbal, regaro1ng mis proJecr. No otner aocumenr will superseaeme requirements of this Purchase Order unless signed
by an authorized agent of each	ty subsequent to the date of this Purchase Order.

Page

2   of	2	Coun,y Ma ria>s'"" 1'-

m a d<bum  C ek COO ,n,;m,Ci---

Florida Admin Rule 12A-1.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The COD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD' s Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The CDD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the COD is a paramount consideration. The COD will be deemed to have assumed the risk of loss if the CDD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The COD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE  OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-80157730 53C-0. affirms that the tangible personal property purchased pursuant to Purchase Order Number 190402 from County Materials (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction. Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ad.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule lZA-1.094, F.A.C.:

You must initial each of the following requirements.

4..

The attached Purchase Order is issued directly to the vendor supplying the tangible personal property the Contractor will use in the identified public works.
Th e vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from p funds.
'ti,2::::-4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
purchase or of delivery by the vendor.
'etJs.Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached  Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

1 understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

By:	

Its:  	

C:/..(../.OtY'	_

Fede ral Employer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

You must attach a copy of the Purchase Order to this Certificate of Entitlement.

Do not s end to the Florida De pa r tme nt of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February !, 2019 (the Master Indenture as amended and supplemented is hereinafter refened to as the "Indenture") (all capitalized te1ms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-56

Ferguson Waterworks FEI-PT.  Charlotte #1705
18305 Paulson  Drive Port Charlotte,  FL 33954

Amount Payable:	$16,708.61

Purpose for which paid or incU1Ted (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Direct purchase of material for construction of Grand Pahn, Phase lB(a). Purchase Order# 180601; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount  set forth  above have beeu incU1Ted by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incuned in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance  Account  that  has not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such reqms1tion contains  no  item representing payment on account of any retained percentage which the District  is at  the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACK.BURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:		AJ'/
Authonzed Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

-i.J ½c

lf this requisition is for a disbursement from other than Costs oflssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof

Consulting Engineer

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February !, 2019 (the Master Indenture as amended and supplemented is hereinafter refened to as the "Indenture") (all capitalized te1ms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-56

Ferguson Waterworks FEI-PT.  Charlotte #1705
18305 Paulson  Drive Port Charlotte,  FL 33954

Amount Payable:	$16,708.61

Purpose for which paid or incU1Ted (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Direct purchase of material for construction of Grand Pahn, Phase lB(a). Purchase Order# 180601; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount  set forth  above have beeu incU1Ted by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incuned in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance  Account  that  has not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such reqms1tion contains  no  item representing payment on account of any retained percentage which the District  is at  the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACK.BURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:		AJ'/
Authonzed Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

-i.J ½c

lf this requisition is for a disbursement from other than Costs oflssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof

Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Ferguson Waterworks Project:	Phase 1B(a)

    Invoice #	Amount	
    1415136	$16,708.61 
Sub-Total	$16,708.61

ff FERGUSON
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

NOV O 5 2019

    INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1415136	$16,708.61	41951	1 of 1	

PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127 PO BOX 100286
ATLANTA, GA 30384-0286

 	SHIP TO:	

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PH1BA
C/O FORSBERG CONSTRUCTION INC
PO#180601
PUNTA GORDA, FL 33950

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PH1BA
C/O FORSBERG CONSTRUCTION INC 645 CHARLOTTE ST

SHIP WHSE.
1705	SELL WHSE.
1705	TAX CODE

FLE	CUSTOMER ORDER NUMBER

180601	SALESMAN

TAE	JOB NAME

PH1BA SOURCE	INVOICE DATE

11/01/19	BATCH
10
81925	
ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	_)JM	AMOUNT
56	37   CWA03111812	11X18X12 BX W/ CI RDR LID SUD	68.000	EA	2516.00
/   112	112   FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	1.260 V EA	141.12
5	5   C1230BHS500	12GA 30MM 500 FT COP TRCR WRE BLUE	89.000 •/     EA	445.00
3	3   PSD3105B52	3X1000 UG DET WTR BLUE	28.000•/    EA	84.00
/    15	15   F202B540CC4	4X1 CC DBL STRP BRZ SOL DI/AC	72.200 /   EA	1083.00
41	41   F202B962CC4	8X1 CC DBL STRP BRZ SOL DI/AC	102.610 /   EA	4207.01
56	56   FBA43444WNL	LF 1 CTS X MTR ANG BV	87.340 , ...- EA	4891.04
f /     56	56    FFB10004NL	LF 1 CC X CTS PJ BALL CORP	50.240 /   EA	2813.44
56	56	CYPSKPX	2X4X8 YELL PINE STUD	3.000 1/    EA	168.00
900	900   PEC9BG300	·exc 1X300 CTS DR9 HOPE BLUE PIPE	40.000 /     C	360.00
INVOICE SUB-TOTAL	16708.61
.......................... .,_.....  ... ......	......	.  ..........................................	..........  ................	.
LE AD  LAW	W RNING: IT IS ILLEI AL TO INSTALL PRODLCTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE W TH
US FEDERAL I ROTHER APPLICABLE LAWIN POTABLE WATER SYSTEMSANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH •NP IN THE DESCR IP TI ON ARE NOT L D FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLI APPLICATIONS. UYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business		
TERMS :	NET 10TH PROX	ORIGINAL INVOICE	TOTAL DUE	$16,708.61	
All past due amounts are subject to a service charge of 1.5% per month, or the maximum allowed by law, if lower. If Buyer fails to pay within terms, then in addition to other remedies, Buyer agrees to pay Seller all costs of collection, including reasonable attorney fees. Complete terms and conditions are available upon request or at
https://www.ferguson.com/content/website-info/terms-of-sale, incorporated by reference. Seller may convert checks to ACH.

rul Ln/"'\.)t: Ul Ut:I l'JU.	/80601

Blackburn Creek Community Development District
c/o
Forsberg Co nstructi on, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (94 l) 637-8500	Fax, (941) 639-1073
Und erground Utility License liCUC0557 l6
Visit Us at \\Ww.forsl>c rgconstructio n.com

Ven dor: Ferguson Waterworks Addr ess: 18305 Paulson Drive
 Port Charlott e, FL 33954	

Job No.: 18-06

P.O. Date: February 22, 2019 Project Name: Grand Palm Phase IBa

Project Addr ess: Obervat ion Blvd off of Center Road

   Venice. Florida	                                         Legal Desc.: Sec: 19 & 20, Twp:39S, Range 20E
County: Sarasota

Payment Terms: Cut-off 25th; 2% by I 0tll of 2ndMonth Vendor Phon e: 941-624-3494		 	

Quantity	Unit

Description

..

Unit Price

Total Price 	

---

    j

[

I

LS

1Pipe, Valves.Fittin gs and Appurtenanc;e in a ccordance
with Exhibit "A" (pages 1-3)

$

-

68,883.70

$

68,883.70

..	 	

----·

--

-

-

-

-·-

..

-

----

-

---
--
.--

--·	-	-
-	-

--

--

----·

-- .
-----·

I. -

-

--

I

--·

Pricesare good for duration of the project.

---

-----	--·
Project Durat ion: Janu ary 1, 2019 - January I, 2020

I
 L-    ....	

--- --

I 	

---

Total Project Subtotal	s
Sales Tax @ 6 %

----

Discre tio nary Tax @_1.0    %   on

- - --

I st $5,000.00
TOTAL

$

68,883.70
tax exempt tax exempt
68,883.70

A tten tion : _!t   ier  Evenson	 		Vendor Fax: 94 1-627-35 19

Ferg uson  W at er w orks    	 Vendor name	··

_  X-	-F-  -	---'-- -	   J	I	I _J  ---	

Blackburn Creek COD

"-:----'  	-	-	-	:f	,l_,}_fL   

Auth	ze   t\g nt (signature)	Date

Authorized

r  nrde/	};	-	-

 		 A1e !  	

Authori	ze  d  Agent (sig n;i ture)	D a t e
! IMPORTANT!

SEESPECIAL PROVISIONS ABOV E.

Page	of	2	ADDITIONAL TERMS ANO CONDITIONS ON PAGE 2

TERMS AND  CONDITIONS
I.	All material sha ll be as spec ified and warranted in accordance to the Project sp ecifications, pl ans and addencla.
Material sh all be within accepted standards for workmanship and quality, and sha ll be satisfactory to me et approval of the Owner, Owner's representative and Purchaser.

When requestedby Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete se t of shop draw ings for Purchaser's r eview and approval. All items suppli ed without prior approval, that do not meet Project requiremen ts,will be returned to Vendor, by Vendor, at no charge to Purcl1aser.

Tim e is of tl1e essen ce.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Venclor sh all notify Purchaser 24 hours in advance of arrival to j obsite to confirm delivery.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/ or transpor ter will be required to hold over until the following work day to be unloaded. Purchaser  will not be responsible  for any demurrage charge for such hold over.

Shou ld the Vendor fail to provide materialas scheduled by Purchaser and Vendor, the Purchaser, up on 3 day written notice to Vendor, shall have the right to procure said materials elsewh ere without further responsibility to Vendor.

Quan titi esare approximate and subject to proj ect requirements.

Vendor agrees to accept without charge to Purchaser, all extra, n on-specialty materials in good concli tion which rem ain a er completion of work and will issue full credit for same.

Vendor shall sign ancl return Purchase Order within IO days of Purchase Or der date. Purchas er w ill return an executed Purchase Order to Vendor.

I 0.		To in sure prompt paymen t, Purchase Order number must appear on all invoicesand copies of signed delivery slips attached.

I I.	Neither party will change, alter, nor sub stitu te any part of this Purchase Order without consent of tile opposit e party. All changes so agreed to sh all be initialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaserw ith ou t receipt of a properly sign ed and acceptable Pur chase Order.

Sh ipm ent of any materials. be for e signin g this Purchase Order, will be considered an acceptance of this Pur chaseOrder.

If V e nd or fails to properly execu te and return Purchase Order within IO days, Purchaser may consid e r offer rejected.

1 5. This agr eement sh all be governed by the laws of th e State of Florida with venue in Charlo tte Coun ty, Florida.

.	The authorized agent sign in g this Purchas e Orde r for the Vendor must be duly authori zed to do so on b ehalf of the Vendor or on behalf of any such disclosed prin cipal.

In the event any of theseterms are declared to be unenforceable by a court of competent j urisdi ction, then Purch aser and Vendor intend for the remaining terms and conditions to rem ain in full force and effect.

This Purchase Order is the only binding contract between Purchaser and Vendor for this proj ect and the work described. This Purchase Order replaces arr previous contracts and  agreements, whether  written or  verbal, regarding this project. No other document will supersedethe requirements of this Purchase Order u nless signed by an authorized agent of each parly subsequen t to the date of this Purchase Order.

Page   2  of	2	Ferguson Initi al	Blackburn Creek COD ln ti tal	-

OeliverTo:
rom:	• Tyler A Evenson Comments:

FERGUSON

8		FEI-PT.CHARLOTTE WW 1705 18305 PAULSON DRIVE

WATERWORKS

PORT CHARLOTTE, FL 33954-0000

Phone: 941-624-3494
Fax: 941-627-3519

12 :30 :10 FEB 25 2019	Page 1 of 4

FEI-PORT CHARLOTTE #1705

Price Quotation Phone: 941-624-3494
Fax : 941 -627-3519

XHI	'

B i d No:
Bid Date:
Quoted By:	B247136
02/25/19
TAE	Cust Phone:
Terms:	941-637-8500
NET 10TH PROX	
Customer:	BLACKBURN CREEK COMMUNITY	Ship To:	BLACKBURN CREEK COMMUNITY	
	GRAND PALM PHASE 18a		GRAND PALM PHASE 18a	
	645 CHARLOTTE ST
PUNTA GORDA, FL 33950		645 CHARLOTTE ST
PUNTA GORDA, FL 33950	

Cust PO#:	180601	Job Name:	GRAND PALM PH 1Ba

Item		Description	Quantity	Net Price	UM	Total 'SEWER•
=====-=====-----===-----=
- 8 " PVC GRAV SWR -
SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE	2030	3.980    FT	8079.40
PD3105G4737	3X1000 UGDET SWR GREE	2	28.000   EA	56.00
SUBTOTAL	8135.40
- SINGLE SWR SRV (4)·
MUL067248	8X6 PVC HW SWR GXGXG 'NYE	4	47.530    EA	190.12
MUL067376	6 PVC HW SWR GXS 45 ELL	12	13.470   EA	161.64
MUL067326	6 PVC HW SWR GXG 45 ELL	4	18.240    EA	72.96
SDR26HWSPU14	6X14 SDR26 HWPVC GJ SWR PIPE	168	2.220    FT 	372.96
MUL067206	6 PVC HW SWR GXGXG 'NYE	4	36.570    EA	146.28
MUL040952	6 PVC SWR HUB FEM CO ADPT	4	11.720   EA	46.88
MUL040958	6 PVC SWR REC THRO CO PLUG	4	8.950    EA	35.80
CYPSKPX	2X4X8 YELL PINE STUD	4	3.000    EA	12.00
MUL043988	6 PVC SWR GSKT CAP	8	6.930    EA	55.44
SUBTOTAL	1094.08
- DBL SWR SRV (26) -

8X6 PVC HW SWR GXGXG 'NYE	26	47.530	EA	1235.78	
6 PVC HW SWR GXS 45 ELL	78	13.470	EA	1050.66	
6 PVC HW SWR GXG 45 ELL	26	18.240	EA	474.24	
6 PVC HW SWR GXG DBL WYE	26	68.260	EA	1774.76	
6 PVC SWR HUB FEM CO ADPT	26	11.720	EA	304.72	
6 PVC SWR REC THRO CO PLUG	26	8.950	EA	232.70	
6 PVC SWR GSKT CAP	78	6.930	EA	540.54	
6X14 SDR26 HW PVC GJ SWR PIPE	1092	2.220	FT	2424.24	
2X4X8 YELL PINE STUD	26	3.000	EA	78.00	
3X1000 UG DET SWR GREE	2	28.000	EA	56.00	
SUBTOTAL				8171.64	

MUL067248 MUL067376 MUL067326 MUL067277 MUL040952 MUL040958 MUL043988 SDR26HWSPU14 CYPSKPX PD3105G4737
TOTAL SANITARYSEWER	17401.12

1$ FERGUSON"

Page 2 of 4
FEI-PORT CHARLOTTE #1705
WATERWORKS	Price Quotation
Fax: 941-627-3519

12:30:10 FEB 25 2019
Reference No; B247136

Item	Description	Quantity	Not Price	UM	Total	
	
WATER MAIN•					
	=== =========== g=========					
	4" PVC WATER MAIN·					
DR18BPP	4 C900 DR18 PVC GJ BLUE PIPE	540	2.080	FT	1123.20	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
G1230BHS600	12GA 30MM 500 FT COP TRCR WIRE BLUE	1	89.000	EA	89.00	
SPWPG4	4 SIGMA BELL REST F/ G900 'PVLOK	8	29.700	EA	237.60	
	SUBTOTAL				1477.80	
	-FITTINGS-					
MJ4LAP	4 MJ G153 45 BEND UA	2	29.240	EA	58.48	
SSLCE4AP	4 PVC WDG REST "ONELOK W/A	4	29.990	EA	119.96	
	SUBTOTAL				178.44	
	
4" GATE VLV ASSM (2) -					
AFC2604DLAFMM	4 DI MJ RW OL SS STEM VLV UA	2	318.430	EA	638.86	
SSLCE4AP	4 PVC WDG REST 'ONELOK W/A	4	29.990	EA	119.98	
1481SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMP	3 BRS GATE VLV ID- 4	2	13.000	EA	26.00	
	SUBTOTAL				972.82	
	
- 8" PVC WTR MAIN -					
DR18BPX	8 C900 DR18 PVC GJ BLUE PIPE	2000	6.700	FT	13400.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	58.00	
C1230BHS500	12GA 30MM 500 FT COP TRGR WIRE BLUE	4	89.000	EA	358.00	

8 SIGMA BELL REST F/ COOO "PVLOK	42	60.050	EA	2102.10	
SUBTOTAL				15914.10	

SPWPC8

8" FITTINGS -

MJ2LAX	8 MJ C163 22-112 BEND UA	8	88.900	EA	413.40	
MJTLAX	8 MJ C163 TEE UA	1	127.850	EA	127.65	
MJRLAXP	8X4 MJ C153 RED UA	1	46.400	EA	48.40	
SSLCE8AP	8 PVC WDG REST "ONELOK W/A	28	46.150	EA	1292.20	

MJ4LAX	8 MJ C153 45 BEND UA	6	68.700   EA	412.20
SSLGE4AP	4 PVC WDG REST 'ONELOK W/A	1	29.990    EA	29.99

- 8" GATE VLV ASSM (4) -

8 DI MJ RW OL SS STEM VLV UA	
4	

647.000	

EA	

2588.00	
8 PVC WDG REST •ONELOK WIA	8	46.160	EA	369.20	
2PG SC GI VLV BX 19-22 WTR	4	95.000	EA	380.00	
3BRSGATEVLVID-8	4	13.000	EA	52.00	
SUBTOTAL				3389.20	
- FIRE HYD ASSM (2) -					
8X6 MJ G153 SWVL TEE UA	2	122.790	EA	245.58	
8 PVC WDG REST 'ONELOK WIA	4	46.150	EA	184.60	
6 PVC WDG REST 'ONELOK WIA	4	34.040	EA	138.16	
6 MJ C153 BLT GSKT PK UGLAND	2	12.700	EA	25.40	
6 DI MJ RW Ol SS STEM VLV UA	2	406.555	EA	813.11	
2PC SC Ci VLV BX 19-22 WTR	2	95.000	EA	190.00	

SUBTOTAL	2321.84
AFC2608DLAFMM SSLGE8AP 1461SW RBGVTMX

MJSTLAXU SSLGE8AF SSLCE6AP IMJBGPU AFC26060LAFMM
1461SW RBGVTMU DR18BPU

3 BRS GATE VLV ID-6	2	13.000	EA	
6 C900 DR18 PVC GJ BLUE PIPE	20	3.860	FT	

26.00
77.20

� FERGUSON®
WATERWORKS

FEI-PORT CHARLOTTE #1705
Price Quotation

Fax: 941-627-3519

Page 3 of4

12:30:10 FEB 25 2019
Reference No: B247136

Item
AFCB84BlAOlP	Description
5-114 Vo B848 HYO 4'0 ol UA	Quantity	Net Price
------ms:ooo	UM
""EA""	Total

2850.00	
	SUBTOTAL				4548.05	
	SINGLE SHORT (34) •					
FS90404	4X1 CC BRS SDL C900	9	72.200	EA	849.80	
FS90804	ax1 cc BRS SDL C900	25	102.610	EA	2565.25	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	34	50.240	EA	1708.16	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	600	40.000	C	240.00	
PEC9BG100	"EXC 1X100 CTS ORS HDPE BLUE PIPE	100	40.000	C	40.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	2	89.000	EA	178.00	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	34	87.340	EA	2969.56	
FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	68	1.260	EA	85.68	
CYPSKPX	2X4X8 YELL PINE STUD	34	3.000	EA	102.00	
CWA03111812	11X18X12 BX W/CI RDR LID SUD	34	68.000	EA	2312.00	
	SUBTOTAL				10878.45	
	SINGLE LONG (22) •					
FS90404	4X1 CC BRS SOL C900	6	72.200	EA	433.20	
FS90804	ax, cc BRS SOL C900	16	102.610	EA	1841.76	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	22	50.240	EA	1105.28	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	1200	40.000	C	480.00	
PEC9BG100	"EXC 1X100 CTS DR9 HDPE BLUE PIPE	100	40.000	C	40.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	3	89.000	EA	267.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	56.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	22	87.340	EA	1921.48	
FINSERT52	1 CT$ PET/ HOPE DR9 INS STFNR	44	1.260	EA	55.44	
CYPSKPX	2X4X8 YELL PINE STUD	22	3.000	EA	66.00	
CWA03111812	11X18X12 BX W/CIRDR LID SUD	22	68.000	EA	1498.00	
SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	880	0.550	FT	484.00	
	SUBTOTAL				8046.16	
FBLSLAX	BX12 MJ C110 LONG SLV UA	1	123.300	EA	123.30	
SSLCE8AP	8 PVC WDG REST 'ONELOK WIA	2	48.150	EA	92.30	
	SUBTOTAL				216.60	
	8X8 HOTTAP (2) •					
J4320900X8	8X8 SS TAPN SLV 8.60-9.05	2	788.610	EA	1577.02	
AFC2608DLAFTM	8 DI MJ RWOLSS TAPNVLV UA	2	827.400	EA	1654.80	
1461SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMX	3 BRS GATE VLV ID- 8	2	13.000	EA	26.00	
SSLCE8AP	8 PVC WDG REST "ONELOK WIA	2	46.150	EA	92.30	
	SUBTOTAL				3540.12	
NetTotal:	$68883.70	
Tax:	$0.00	
Freight:	$0.00	
Total:	$68883.70	

Florida Admin Rule 12A-I.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The CDD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD's Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The COD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the CDD is a paramount consideration. The CDD will be deemed to have assumed the risk ofloss if the COD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The COD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTI FICATE OF ENTITLEMEN T
The und ersigned authorized representative of the Blackburn Creek Community Development District, a local unit of specia l purpose government (hereinafter "Go vernme ntal Entity"), Florida Consum er's Ce r ti ficate of Exe mpt io n Num ber 85-8015773053C-0.affir ms that the tangible personal property pur chased pu,·s uan t to Purchase Order Number 180601 from Ferguson Wa terw or ks (Vendor) on or after 2 /22/19 (date) will be incorporated into or become a part of a public facility as par t of a public works contr act pursuant to contract# n.li!. with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Pur chase Ord er meets the following exe mpt ion requirements conta ined in Section 21 2.08( 6). F.S., a nd Rule 12A-l.094, F.A.C.:

You 11111st initial each oft he folfowi11g requirements.

The attached Purchase Order is iss ued directly to the vendor supplyin g the  tangible  personal  pro )Crty the Contractor will use in the identified public works.
The vendo r"s invoice will be issued directly to Governmental Entity.
. Payment of the vendor"s inv oice will be made directly by Governmental Entity to the vend o r from pub ic fund s.
-	Governmental Entity will take title to the tangible personal property from the vendor at the time of pth-cl1ase or of delive1y by the vendor.
A	. 5. Government al Entity assumes the risk of damage or loss at the time of purchase or delivery by the

Go vernment al Entity affirm s that if the tangible personal property identified in the attached Pur chase Ord er does not qualify for the exemption provided in Section 212. 08 (6 ), F.S. and Rule 12 A-1. 0 9 4 , F.A.C.. Governme ntal Entity will be subject to the tax, interest, and penalties due on the tangible personal p roperty purchased. If th e  Florida Department of Revenue deter mines  that the tangible  personal property pur chased
tax-exempt by issu ing this Ce rtifi cate does not qualify for the exemption,Governmenta l Entity will be liable for any tax, penalty, and interest determined to be clue.

I unders tand that if I fraudulently issue th is certificate to evade the payment of sa les tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

U nder the penalties of perjury. I declare that I hav e read the foregoing Ce rtifi cate of Entitlement and the
facts stated in it are true.

Q	

Blackbu rn Creek Communit y Development District, a local uni t of special pur pose government By:

Federal Empl oyer Identification Numb er: -   --   -   -   -   - -  -	=	­

You must attach a copy of the Pu rc hase Order to this Certificate of Ent itle ment.

Do not send to the Florida Depar tment of Revenue. This Certificate of Entitlement mus t be retain ed in the
vendor's and the cont ractor's books and records.

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Ferguson Waterworks Project:	Phase 1B(a)

    Invoice #	Amount	
    1415136	$16,708.61 
Sub-Total	$16,708.61

ff FERGUSON
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

NOV O 5 2019

    INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1415136	$16,708.61	41951	1 of 1	

PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127 PO BOX 100286
ATLANTA, GA 30384-0286

 	SHIP TO:	

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PH1BA
C/O FORSBERG CONSTRUCTION INC
PO#180601
PUNTA GORDA, FL 33950

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PH1BA
C/O FORSBERG CONSTRUCTION INC 645 CHARLOTTE ST

SHIP WHSE.
1705	SELL WHSE.
1705	TAX CODE

FLE	CUSTOMER ORDER NUMBER

180601	SALESMAN

TAE	JOB NAME

PH1BA SOURCE	INVOICE DATE

11/01/19	BATCH
10
81925	
ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	_)JM	AMOUNT
56	37   CWA03111812	11X18X12 BX W/ CI RDR LID SUD	68.000	EA	2516.00
/   112	112   FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	1.260 V EA	141.12
5	5   C1230BHS500	12GA 30MM 500 FT COP TRCR WRE BLUE	89.000 •/     EA	445.00
3	3   PSD3105B52	3X1000 UG DET WTR BLUE	28.000•/    EA	84.00
/    15	15   F202B540CC4	4X1 CC DBL STRP BRZ SOL DI/AC	72.200 /   EA	1083.00
41	41   F202B962CC4	8X1 CC DBL STRP BRZ SOL DI/AC	102.610 /   EA	4207.01
56	56   FBA43444WNL	LF 1 CTS X MTR ANG BV	87.340 , ...- EA	4891.04
f /     56	56    FFB10004NL	LF 1 CC X CTS PJ BALL CORP	50.240 /   EA	2813.44
56	56	CYPSKPX	2X4X8 YELL PINE STUD	3.000 1/    EA	168.00
900	900   PEC9BG300	·exc 1X300 CTS DR9 HOPE BLUE PIPE	40.000 /     C	360.00
INVOICE SUB-TOTAL	16708.61
.......................... .,_.....  ... ......	......	.  ..........................................	..........  ................	.
LE AD  LAW	W RNING: IT IS ILLEI AL TO INSTALL PRODLCTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE W TH
US FEDERAL I ROTHER APPLICABLE LAWIN POTABLE WATER SYSTEMSANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH •NP IN THE DESCR IP TI ON ARE NOT L D FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLI APPLICATIONS. UYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business		
TERMS :	NET 10TH PROX	ORIGINAL INVOICE	TOTAL DUE	$16,708.61	
All past due amounts are subject to a service charge of 1.5% per month, or the maximum allowed by law, if lower. If Buyer fails to pay within terms, then in addition to other remedies, Buyer agrees to pay Seller all costs of collection, including reasonable attorney fees. Complete terms and conditions are available upon request or at
https://www.ferguson.com/content/website-info/terms-of-sale, incorporated by reference. Seller may convert checks to ACH.

rul Ln/"'\.)t: Ul Ut:I l'JU.	/80601

Blackburn Creek Community Development District
c/o
Forsberg Co nstructi on, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (94 l) 637-8500	Fax, (941) 639-1073
Und erground Utility License liCUC0557 l6
Visit Us at \\Ww.forsl>c rgconstructio n.com

Ven dor: Ferguson Waterworks Addr ess: 18305 Paulson Drive
 Port Charlott e, FL 33954	

Job No.: 18-06

P.O. Date: February 22, 2019 Project Name: Grand Palm Phase IBa

Project Addr ess: Obervat ion Blvd off of Center Road

   Venice. Florida	                                         Legal Desc.: Sec: 19 & 20, Twp:39S, Range 20E
County: Sarasota

Payment Terms: Cut-off 25th; 2% by I 0tll of 2ndMonth Vendor Phon e: 941-624-3494		 	

Quantity	Unit

Description

..

Unit Price

Total Price 	

---

    j

[

I

LS

1Pipe, Valves.Fittin gs and Appurtenanc;e in a ccordance
with Exhibit "A" (pages 1-3)

$

-

68,883.70

$

68,883.70

..	 	

----·

--

-

-

-

-·-

..

-

----

-

---
--
.--

--·	-	-
-	-

--

--

----·

-- .
-----·

I. -

-

--

I

--·

Pricesare good for duration of the project.

---

-----	--·
Project Durat ion: Janu ary 1, 2019 - January I, 2020

I
 L-    ....	

--- --

I 	

---

Total Project Subtotal	s
Sales Tax @ 6 %

----

Discre tio nary Tax @_1.0    %   on

- - --

I st $5,000.00
TOTAL

$

68,883.70
tax exempt tax exempt
68,883.70

A tten tion : _!t   ier  Evenson	 		Vendor Fax: 94 1-627-35 19

Ferg uson  W at er w orks    	 Vendor name	··

_  X-	-F-  -	---'-- -	   J	I	I _J  ---	

Blackburn Creek COD

"-:----'  	-	-	-	:f	,l_,}_fL   

Auth	ze   t\g nt (signature)	Date

Authorized

r  nrde/	};	-	-

 		 A1e !  	

Authori	ze  d  Agent (sig n;i ture)	D a t e
! IMPORTANT!

SEESPECIAL PROVISIONS ABOV E.

Page	of	2	ADDITIONAL TERMS ANO CONDITIONS ON PAGE 2

TERMS AND  CONDITIONS
I.	All material sha ll be as spec ified and warranted in accordance to the Project sp ecifications, pl ans and addencla.
Material sh all be within accepted standards for workmanship and quality, and sha ll be satisfactory to me et approval of the Owner, Owner's representative and Purchaser.

When requestedby Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete se t of shop draw ings for Purchaser's r eview and approval. All items suppli ed without prior approval, that do not meet Project requiremen ts,will be returned to Vendor, by Vendor, at no charge to Purcl1aser.

Tim e is of tl1e essen ce.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Venclor sh all notify Purchaser 24 hours in advance of arrival to j obsite to confirm delivery.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/ or transpor ter will be required to hold over until the following work day to be unloaded. Purchaser  will not be responsible  for any demurrage charge for such hold over.

Shou ld the Vendor fail to provide materialas scheduled by Purchaser and Vendor, the Purchaser, up on 3 day written notice to Vendor, shall have the right to procure said materials elsewh ere without further responsibility to Vendor.

Quan titi esare approximate and subject to proj ect requirements.

Vendor agrees to accept without charge to Purchaser, all extra, n on-specialty materials in good concli tion which rem ain a er completion of work and will issue full credit for same.

Vendor shall sign ancl return Purchase Order within IO days of Purchase Or der date. Purchas er w ill return an executed Purchase Order to Vendor.

I 0.		To in sure prompt paymen t, Purchase Order number must appear on all invoicesand copies of signed delivery slips attached.

I I.	Neither party will change, alter, nor sub stitu te any part of this Purchase Order without consent of tile opposit e party. All changes so agreed to sh all be initialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaserw ith ou t receipt of a properly sign ed and acceptable Pur chase Order.

Sh ipm ent of any materials. be for e signin g this Purchase Order, will be considered an acceptance of this Pur chaseOrder.

If V e nd or fails to properly execu te and return Purchase Order within IO days, Purchaser may consid e r offer rejected.

1 5. This agr eement sh all be governed by the laws of th e State of Florida with venue in Charlo tte Coun ty, Florida.

.	The authorized agent sign in g this Purchas e Orde r for the Vendor must be duly authori zed to do so on b ehalf of the Vendor or on behalf of any such disclosed prin cipal.

In the event any of theseterms are declared to be unenforceable by a court of competent j urisdi ction, then Purch aser and Vendor intend for the remaining terms and conditions to rem ain in full force and effect.

This Purchase Order is the only binding contract between Purchaser and Vendor for this proj ect and the work described. This Purchase Order replaces arr previous contracts and  agreements, whether  written or  verbal, regarding this project. No other document will supersedethe requirements of this Purchase Order u nless signed by an authorized agent of each parly subsequen t to the date of this Purchase Order.

Page   2  of	2	Ferguson Initi al	Blackburn Creek COD ln ti tal	-

OeliverTo:
rom:	• Tyler A Evenson Comments:

FERGUSON

8		FEI-PT.CHARLOTTE WW 1705 18305 PAULSON DRIVE

WATERWORKS

PORT CHARLOTTE, FL 33954-0000

Phone: 941-624-3494
Fax: 941-627-3519

12 :30 :10 FEB 25 2019	Page 1 of 4

FEI-PORT CHARLOTTE #1705

Price Quotation Phone: 941-624-3494
Fax : 941 -627-3519

XHI	'

B i d No:
Bid Date:
Quoted By:	B247136
02/25/19
TAE	Cust Phone:
Terms:	941-637-8500
NET 10TH PROX	
Customer:	BLACKBURN CREEK COMMUNITY	Ship To:	BLACKBURN CREEK COMMUNITY	
	GRAND PALM PHASE 18a		GRAND PALM PHASE 18a	
	645 CHARLOTTE ST
PUNTA GORDA, FL 33950		645 CHARLOTTE ST
PUNTA GORDA, FL 33950	

Cust PO#:	180601	Job Name:	GRAND PALM PH 1Ba

Item		Description	Quantity	Net Price	UM	Total 'SEWER•
=====-=====-----===-----=
- 8 " PVC GRAV SWR -
SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE	2030	3.980    FT	8079.40
PD3105G4737	3X1000 UGDET SWR GREE	2	28.000   EA	56.00
SUBTOTAL	8135.40
- SINGLE SWR SRV (4)·
MUL067248	8X6 PVC HW SWR GXGXG 'NYE	4	47.530    EA	190.12
MUL067376	6 PVC HW SWR GXS 45 ELL	12	13.470   EA	161.64
MUL067326	6 PVC HW SWR GXG 45 ELL	4	18.240    EA	72.96
SDR26HWSPU14	6X14 SDR26 HWPVC GJ SWR PIPE	168	2.220    FT 	372.96
MUL067206	6 PVC HW SWR GXGXG 'NYE	4	36.570    EA	146.28
MUL040952	6 PVC SWR HUB FEM CO ADPT	4	11.720   EA	46.88
MUL040958	6 PVC SWR REC THRO CO PLUG	4	8.950    EA	35.80
CYPSKPX	2X4X8 YELL PINE STUD	4	3.000    EA	12.00
MUL043988	6 PVC SWR GSKT CAP	8	6.930    EA	55.44
SUBTOTAL	1094.08
- DBL SWR SRV (26) -

8X6 PVC HW SWR GXGXG 'NYE	26	47.530	EA	1235.78	
6 PVC HW SWR GXS 45 ELL	78	13.470	EA	1050.66	
6 PVC HW SWR GXG 45 ELL	26	18.240	EA	474.24	
6 PVC HW SWR GXG DBL WYE	26	68.260	EA	1774.76	
6 PVC SWR HUB FEM CO ADPT	26	11.720	EA	304.72	
6 PVC SWR REC THRO CO PLUG	26	8.950	EA	232.70	
6 PVC SWR GSKT CAP	78	6.930	EA	540.54	
6X14 SDR26 HW PVC GJ SWR PIPE	1092	2.220	FT	2424.24	
2X4X8 YELL PINE STUD	26	3.000	EA	78.00	
3X1000 UG DET SWR GREE	2	28.000	EA	56.00	
SUBTOTAL				8171.64	

MUL067248 MUL067376 MUL067326 MUL067277 MUL040952 MUL040958 MUL043988 SDR26HWSPU14 CYPSKPX PD3105G4737
TOTAL SANITARYSEWER	17401.12

1$ FERGUSON"

Page 2 of 4
FEI-PORT CHARLOTTE #1705
WATERWORKS	Price Quotation
Fax: 941-627-3519

12:30:10 FEB 25 2019
Reference No; B247136

Item	Description	Quantity	Not Price	UM	Total	
	
WATER MAIN•					
	=== =========== g=========					
	4" PVC WATER MAIN·					
DR18BPP	4 C900 DR18 PVC GJ BLUE PIPE	540	2.080	FT	1123.20	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
G1230BHS600	12GA 30MM 500 FT COP TRCR WIRE BLUE	1	89.000	EA	89.00	
SPWPG4	4 SIGMA BELL REST F/ G900 'PVLOK	8	29.700	EA	237.60	
	SUBTOTAL				1477.80	
	-FITTINGS-					
MJ4LAP	4 MJ G153 45 BEND UA	2	29.240	EA	58.48	
SSLCE4AP	4 PVC WDG REST "ONELOK W/A	4	29.990	EA	119.96	
	SUBTOTAL				178.44	
	
4" GATE VLV ASSM (2) -					
AFC2604DLAFMM	4 DI MJ RW OL SS STEM VLV UA	2	318.430	EA	638.86	
SSLCE4AP	4 PVC WDG REST 'ONELOK W/A	4	29.990	EA	119.98	
1481SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMP	3 BRS GATE VLV ID- 4	2	13.000	EA	26.00	
	SUBTOTAL				972.82	
	
- 8" PVC WTR MAIN -					
DR18BPX	8 C900 DR18 PVC GJ BLUE PIPE	2000	6.700	FT	13400.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	58.00	
C1230BHS500	12GA 30MM 500 FT COP TRGR WIRE BLUE	4	89.000	EA	358.00	

8 SIGMA BELL REST F/ COOO "PVLOK	42	60.050	EA	2102.10	
SUBTOTAL				15914.10	

SPWPC8

8" FITTINGS -

MJ2LAX	8 MJ C163 22-112 BEND UA	8	88.900	EA	413.40	
MJTLAX	8 MJ C163 TEE UA	1	127.850	EA	127.65	
MJRLAXP	8X4 MJ C153 RED UA	1	46.400	EA	48.40	
SSLCE8AP	8 PVC WDG REST "ONELOK W/A	28	46.150	EA	1292.20	

MJ4LAX	8 MJ C153 45 BEND UA	6	68.700   EA	412.20
SSLGE4AP	4 PVC WDG REST 'ONELOK W/A	1	29.990    EA	29.99

- 8" GATE VLV ASSM (4) -

8 DI MJ RW OL SS STEM VLV UA	
4	

647.000	

EA	

2588.00	
8 PVC WDG REST •ONELOK WIA	8	46.160	EA	369.20	
2PG SC GI VLV BX 19-22 WTR	4	95.000	EA	380.00	
3BRSGATEVLVID-8	4	13.000	EA	52.00	
SUBTOTAL				3389.20	
- FIRE HYD ASSM (2) -					
8X6 MJ G153 SWVL TEE UA	2	122.790	EA	245.58	
8 PVC WDG REST 'ONELOK WIA	4	46.150	EA	184.60	
6 PVC WDG REST 'ONELOK WIA	4	34.040	EA	138.16	
6 MJ C153 BLT GSKT PK UGLAND	2	12.700	EA	25.40	
6 DI MJ RW Ol SS STEM VLV UA	2	406.555	EA	813.11	
2PC SC Ci VLV BX 19-22 WTR	2	95.000	EA	190.00	

SUBTOTAL	2321.84
AFC2608DLAFMM SSLGE8AP 1461SW RBGVTMX

MJSTLAXU SSLGE8AF SSLCE6AP IMJBGPU AFC26060LAFMM
1461SW RBGVTMU DR18BPU

3 BRS GATE VLV ID-6	2	13.000	EA	
6 C900 DR18 PVC GJ BLUE PIPE	20	3.860	FT	

26.00
77.20

� FERGUSON®
WATERWORKS

FEI-PORT CHARLOTTE #1705
Price Quotation

Fax: 941-627-3519

Page 3 of4

12:30:10 FEB 25 2019
Reference No: B247136

Item
AFCB84BlAOlP	Description
5-114 Vo B848 HYO 4'0 ol UA	Quantity	Net Price
------ms:ooo	UM
""EA""	Total

2850.00	
	SUBTOTAL				4548.05	
	SINGLE SHORT (34) •					
FS90404	4X1 CC BRS SDL C900	9	72.200	EA	849.80	
FS90804	ax1 cc BRS SDL C900	25	102.610	EA	2565.25	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	34	50.240	EA	1708.16	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	600	40.000	C	240.00	
PEC9BG100	"EXC 1X100 CTS ORS HDPE BLUE PIPE	100	40.000	C	40.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	2	89.000	EA	178.00	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	34	87.340	EA	2969.56	
FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	68	1.260	EA	85.68	
CYPSKPX	2X4X8 YELL PINE STUD	34	3.000	EA	102.00	
CWA03111812	11X18X12 BX W/CI RDR LID SUD	34	68.000	EA	2312.00	
	SUBTOTAL				10878.45	
	SINGLE LONG (22) •					
FS90404	4X1 CC BRS SOL C900	6	72.200	EA	433.20	
FS90804	ax, cc BRS SOL C900	16	102.610	EA	1841.76	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	22	50.240	EA	1105.28	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	1200	40.000	C	480.00	
PEC9BG100	"EXC 1X100 CTS DR9 HDPE BLUE PIPE	100	40.000	C	40.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	3	89.000	EA	267.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	56.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	22	87.340	EA	1921.48	
FINSERT52	1 CT$ PET/ HOPE DR9 INS STFNR	44	1.260	EA	55.44	
CYPSKPX	2X4X8 YELL PINE STUD	22	3.000	EA	66.00	
CWA03111812	11X18X12 BX W/CIRDR LID SUD	22	68.000	EA	1498.00	
SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	880	0.550	FT	484.00	
	SUBTOTAL				8046.16	
FBLSLAX	BX12 MJ C110 LONG SLV UA	1	123.300	EA	123.30	
SSLCE8AP	8 PVC WDG REST 'ONELOK WIA	2	48.150	EA	92.30	
	SUBTOTAL				216.60	
	8X8 HOTTAP (2) •					
J4320900X8	8X8 SS TAPN SLV 8.60-9.05	2	788.610	EA	1577.02	
AFC2608DLAFTM	8 DI MJ RWOLSS TAPNVLV UA	2	827.400	EA	1654.80	
1461SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMX	3 BRS GATE VLV ID- 8	2	13.000	EA	26.00	
SSLCE8AP	8 PVC WDG REST "ONELOK WIA	2	46.150	EA	92.30	
	SUBTOTAL				3540.12	
NetTotal:	$68883.70	
Tax:	$0.00	
Freight:	$0.00	
Total:	$68883.70	

Florida Admin Rule 12A-I.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The CDD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD's Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The COD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the CDD is a paramount consideration. The CDD will be deemed to have assumed the risk ofloss if the COD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The COD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTI FICATE OF ENTITLEMEN T
The und ersigned authorized representative of the Blackburn Creek Community Development District, a local unit of specia l purpose government (hereinafter "Go vernme ntal Entity"), Florida Consum er's Ce r ti ficate of Exe mpt io n Num ber 85-8015773053C-0.affir ms that the tangible personal property pur chased pu,·s uan t to Purchase Order Number 180601 from Ferguson Wa terw or ks (Vendor) on or after 2 /22/19 (date) will be incorporated into or become a part of a public facility as par t of a public works contr act pursuant to contract# n.li!. with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Pur chase Ord er meets the following exe mpt ion requirements conta ined in Section 21 2.08( 6). F.S., a nd Rule 12A-l.094, F.A.C.:

You 11111st initial each oft he folfowi11g requirements.

The attached Purchase Order is iss ued directly to the vendor supplyin g the  tangible  personal  pro )Crty the Contractor will use in the identified public works.
The vendo r"s invoice will be issued directly to Governmental Entity.
. Payment of the vendor"s inv oice will be made directly by Governmental Entity to the vend o r from pub ic fund s.
-	Governmental Entity will take title to the tangible personal property from the vendor at the time of pth-cl1ase or of delive1y by the vendor.
A	. 5. Government al Entity assumes the risk of damage or loss at the time of purchase or delivery by the

Go vernment al Entity affirm s that if the tangible personal property identified in the attached Pur chase Ord er does not qualify for the exemption provided in Section 212. 08 (6 ), F.S. and Rule 12 A-1. 0 9 4 , F.A.C.. Governme ntal Entity will be subject to the tax, interest, and penalties due on the tangible personal p roperty purchased. If th e  Florida Department of Revenue deter mines  that the tangible  personal property pur chased
tax-exempt by issu ing this Ce rtifi cate does not qualify for the exemption,Governmenta l Entity will be liable for any tax, penalty, and interest determined to be clue.

I unders tand that if I fraudulently issue th is certificate to evade the payment of sa les tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

U nder the penalties of perjury. I declare that I hav e read the foregoing Ce rtifi cate of Entitlement and the
facts stated in it are true.

Q	

Blackbu rn Creek Communit y Development District, a local uni t of special pur pose government By:

Federal Empl oyer Identification Numb er: -   --   -   -   -   - -  -	=	­

You must attach a copy of the Pu rc hase Order to this Certificate of Ent itle ment.

Do not send to the Florida Depar tment of Revenue. This Certificate of Entitlement mus t be retain ed in the
vendor's and the cont ractor's books and records.

Blackburn Creek Community Development District
FORM OF REQUISffiON FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the tenns of the Master Trust Indenture from  the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trnstee"), dated as of March I, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from  the  District  to  the Trustee, dated as of February I, 2019 (the Master  Indenture  as  amended  and supplemented is hereinafter referred to as the "Indenture") (all capitalized  tenns  used herein shall have the meaning ascribed to such tenn in the Indenture);

(A)

(Bl

Requisition Number: Name of Payee:

2019-57

County Materials Corp. P.O.Box435
Astatula, FL 34705

Amount Payable:	$25,064.60

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs of Issuance, if applicable):

Direct purchase of material for construction of Grand Palm, Phase 2A(d). Purchase Order# 190402; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount set forth  above  have been incurred by the District, that each disbursement set forth above  is a  proper charge against the Series 20l 9 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account  that  has not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such reqms1t1on contains no  item representing payment on account of any retained percentage which the District is at  the  date of such certificate entitled to retain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

B�		/1	L	
Authorized Officer C7 

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and po1tion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.
w
Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 2A(d)

    Invoice #	Amount	
149188-12	$3,611.92	
149188-13	$3,611.92	
149188-14	$3,611.92	
149188-15	$5,235.84	
149188-16	$4,885.40	
   149188-17	$4,107.60	
Sub-Total	$25,064.60

COUNTY

SHIPPED	INVOICE OATE	I	ORDER NO.	
11 /04/19	11/04/19	I	149188-12	
I	P.O. NO.	I	PAGE#	
44	I ct	190402	I 1 of 1	

(866) 343-8488 Fax (352) 343-0471

NOV 11 20·19	INVOICE

MATERIALS CORPORATION

AST ATULA, FL 34 705-0435

REMIT TO:
PO  BOX 38

CUST #:	3275	MARATHON, WI 54448-0038
Grand Palm Phase 2AD
SHIP ro: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET

I

PUNT A GORDA FL 33950

LINE  I	PRODUCT
NO .	AND DESCRIPTION

QTY. SHIPPED

QT Y.

I

I

I

UIM

UNIT
,    PRICE

AMOUNT (NET)

5	230380s
30" RCP CL3 SMALL BELL
6	230s
30" RCCP GASKET SMALL BELL #839230

104. 00	LF	34 , 73	3611.   9 2

13 . 00	EA	0. 00	0.00

Total	/   3611. 92
Invoice Total	3611.92

COUNTY

SHIPPED	INVO ICE DATE	I	ORDER NO .	
11 /04/19	11/04/19	I	149188 -1 3	
I	P.O. NO.		I	PAGE#	
44	I ct	190402		I 1 of 1	

. (866) 343-8488 Fax (352) 343-0471

NOV ' ' 2019

INVOICE

MATERIALS CORPORATION

AST ATULA, FL 34 70 5-0 435

REMIT TO:
PO BOX 38

CUST #:	3275	MARATHON, WI 54448 -0038
Grand Palm Phase 2AD
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORDA FL 33950

LINEI	PRODUCT	I	QT Y.
1 SHIPPED
104. 00

/   13 . 00	I	QTY . I	UNIT
U/M	/    PRICE
LF	v   34.  73

EA	0 . 00

Total
Invoice Total	I	AMOUNT (NET)
1 361 1. 9 2

0. 00

3611. 92
3611 . 92	
NO .	AND DESCRIPTION							
5	230380s							
	30" RCP CL3 SMALL BELL							
6	230s							
	30" RCCP GASKET SMALL BELL #839230							

COUN TY

MATERIALS CORPORATION
CUST #:	3275
Grand Palm Phase 2AD

SHIPPED	INVOICE DATE	I	ORDER NO .	
11/05/19	11/05/19	I	149188-14	
I	P.O. NO.	I	PAGE#	
44	I ct	190402	I 1 of 1	

SHIP rn, Sarasota County

. (866) 343-8488 Fax (352) 343-0471
ASTATULA, FL 34705-0435

REMIT TO:
PO BOX 38
MARATHON, WI 54448-0038

NOV 1 1 20'i9	INVOICE

Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURN CREEK CDD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORDA FL 33950

LINEI NO.	PRODUCT AND DESCRIPTION	I	QTY. SHIPPED	I	QTY.   I	UNIT
U/M	PRICE	I	AMOUNT
, (NET)	
5	230380s		104. 00		LF	V' 34. 73		/ 361 1. 9 2	
	30" RCP CL3 SMALL BELL							
6	230s		/ 13 . 00		EA	0. 00		0.00	
	30" RCCP GASKET SMALL BELL #839230							
					Total		3611. 92	
					Invoice Total		3611. 92	

COUNTY

SHIPPED	INVOICE DATE	I	ORDER NO .	
11 /05/19	11 /05/19	I	149188-15	
I	P.O. NO.	I	PAGE #	
44	I ct	190402	I 1 of 1	

. (866) 343-8 488 Fax (352) 343-0471

NOV 1 l 20!9	INVOICE

MATERIALS C O R PO R AT I O N

ASTATULA, FL 3 470 5-0 43 5

REMIT TO: PO BOX 38

C U ST #:	3275	MARAT HON, WI 54 448 -00 38
Grand Palm Phase 2AD
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venic e FL 34292

BILL TO :

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORDA FL 33950

LINE NO.	I	PRODUCT
AND DESCRIPTION	I	QT Y. SHIPPED	I	QTY.	I	UNIT
U/M	,P RICE	I	faOUNT
NETI	
3	224380s	1 20. 00	LFT	v' 24. 45	v 2934. 00	
	24" RCP CL3 SMALL BELL				
4	224ep	15. 00	EA	0. 00	0 . 00	
	24 " RCCP GASKET SMALL BELL				
5	230380s	/	8. 00	LF	34_ 73	277. 84	
	30" RCP CL3 SMALL BELL				
6	230s	/ 1. 00	EA	0. 00	0 . 0 0	

11	30 " RCCP GASKET SMALL BELL #839230
224889s
24" FLARED END SECTION GB SMALL	i/2. oo	
EA	0 12. 00	
20 24 . 00	
			Tot al	/	5235 . 84	
			Invoice Total	523 5. 84	

COUN TY

MATERIALS CORPORATION
CUST #:	3275
Grand Palm Phase 2AD

SHIPPED	IN VO ICE DATE	I	ORDER NO.	
11 /06/19	11/06/19	I	149188-16	
I	P.O. NO.	I	PAGE#	
44	I ct	190402	I 1 of 1	

SHIP TO: Sarasota County

. (866) 343-8488 Fax (352) 343-0471
ASTATULA, FL 34705-0435

REMIT TO:
PO  BOX 38
MARATHON, WI 54448 -0038

NOV 1 2 20!9	INVOICE

Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURN CREEK CDD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORDA FL 33950

LINE NO.	I	PRODUCT
AND DESCRIPTION	I	QTY. SHIPPED	I	
QTY.
U/M	I	UNIT
, PRICE	I	AMOUNT (NET)	
1	218380s	64. 00	LFT	15_ 05	10 27. 20	
	18" RCP CL3 SMALL BELL				
2	218ep	8. 00	EA	0. 00	0. 00	
	18" RCCP GASKET SMALL BELL				
3	224380s	104. 00	LFT	v14. 45	) 2542 . 80	
	24" RCP CL3 SMALL BELL				
4	224ep	13. 00	EA	0. 00	0. 00	
	24" RCCP GASKET SMALL BELL				
12	230889s	/	1. 00	EA	1315. 40	/ 131 5. 40	
	30" FLARED END SECTION GB SMALL BELL				
			Total	.,/4885. 40	
			Invoice Total	4885.40	

COUN TY

MATERIALS CORPORATION
CUST #:	3275
Grand Palm Phase 2AD

SHIPPED	IN VO ICE DATE	I	ORDER NO.	
11 /06/19	11/06/19	I	149188-17	
I	P.O. NO.	I	PAGE#	
44	I ct	190402	I 1 of 1	

SHIP TO: Sarasota County

. (866) 343-8488 Fax (352) 343-0471
ASTATULA, FL 34705-0435

REMIT TO:
PO BOX 38
MARATHON, WI 54448-0038

NOV 1 2 20'i9	INVOICE

Observation Blvd off Center Rd Venice FL 34292

BILL TO :

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNT A GORDA FL 33950

LINE I NO.	
PRODUCT AND DESCRIPTION	I	QTY.	I OUT/MY.	I		
UNIT YRICE	I	
AMOUNT (NET)	
3	224380s		i/ 16 8. 00 LFT	/	24. 45		4107. 60	

4	24" RCP CL3 SMALL BELL
224ep
24" RCCP GASKET SMALL BELL		j 21.  00	EA		
0. 00		
0. 00	
Total	./  4107. 60
Invoice Total	4107. 60	

SHIPPED

PURCHASE ORDER No. 	/90402	

Blackburn Creek
Co1nmunity Develop1nent District
c/ o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 339 50
Phone: (94L) 637 -8500	Fax: (941) 639-1073
Underground Utility License #CUC055716 Visit Us at www.forsbergconsrruction.com

Vendor: County Materials Corporation

Address:   P.O. Box 435	

   Astatula, FL 34705	

Attention: Johnny Smith 941-915-3671

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: ObeNation Blvd off of Center Road Venice, Florida
Legal Desc.:   Sec  19&20,  Twp: 39S,	Range 20E	

County:  Sarasota      	  Payment Terms:  Net 30 days	                                    Vendor Phone: 866-343-8488
Vendor Fax:  352-343-0471	

Quantity	Unit	Description	Unit Price	Total Price	
						
184	+/-	LF	18"RCP	s	16.05		s	2,953.20	
776	+/-	LF	24" RCP	$	24.45		s	18,973 .20	
744	+/-	LF	30" RCP	s	34.73		s	25,839.12	
192	+/-	LF	36" RCP	s	48.53		$	9,317.76	
400	+/-	LF	54"RCP	s	98.03		$	39,212.00	
3	+/-	EA	24 " Flared End Section	s	1,012.00		s	3, 036.00	
2	+/-	EA	30 " Flared End Section	$	1,3 15.40		s	2,630.80	
I	+/-	EA	36• Flared End Section	s	1,562.00		s	, 1 562.00	
I	+/-	EA	54• Flared End Section	$	4,086.70		s	, 4 086 .70	

						
						
		Prices ar e good for duration of the project.				
						
		Project Duration : April I 5, 2019 - April I 5, 2020				
!	Total Project Subtotal	s	107,610.78	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ 1.0 % on 1st $5,000.00	tax exempt	
TOTAL	s	107,6 10.78	

Blackburn Creek COD Chairman

 	-
Authorized Agent /signa tur e}
! IMPORTANT !

Date

Page	 		of	2

,1SEESPECIAL PROVISIONS ABOVE

ADD ITION AL TERMSAND CONDITIONSON PAGE 2

TERMS AND  CONDITIONS
Alf material shall be as specified and warranted in accordance to the Project specifications, plans and addenda. Material shall be within accepted standards for workmanship and quality, and shall be satisfactory to meet approval of the Owner, Owner's representative and Purchase.r

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. Alf items supplied without prior approval, that do not meet Project requirements, will bereturned to Vendor, by Vendor, at no charge to Purchaser.

Time is of the essence.

Delivery of materials to be coordinated by Purchaser in ord er to accommodate unloading. Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the following work day to be unloaded. Purchaser will not beresponsible for any demurrage charge for such hold over.

Should the Vendor fail to provide material as scheduled by Purchaser and Vendor, the Purchaser, upon 3 day written notice to Vendor, shall have the right to procure said materials elsewhere without further responsibility to Vendor.

Quantities are approximate and subject to project requirements.

Vendor agrees to accept without charge to Purchaser, all extra, non-specialty materials in good condition which remain after completion of work and will issue full credit for same.

Vendor shall sign and return Purchase Order within 1O days of Purchase Order date. Purchaser will return an executed Purchase Order to Vendor.

To insure prompt payment, Purchase Order number must appear on all invoices and copies of signed delivery slips attached.

Neith er party will change, alter, nor substitute any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be ini tialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaser without receipt of a properly sign ed and acceptable Purchase Order.

Shipment of any materials, before signing this Purchase Order, will beconsidered an acceptance of this Purchase Ord er.

If Vendor fails to properly execute and return Purchase Order within 1O days, Purchaser may consider offer rejected.

I 5. This agreeme n t shall be governed by the laws of the Stat e of Florida with venue in Charlotte Coun ty, Florida.

16. The authorized agent signing this Purchase Order for the Vendor must be duly authorized to do so on behalf of the Vendor or on behalf of any such disclosed principal.

17.

18 .

In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full force and effect.

This Purchase Order is the only binding contract betw een Purchaser and Vendor for this project and the work

r

described. This Purchase Order replaces all previous contracts and agreements,w heth  er written or  verbal, regaro1ng mis proJecr. No otner aocumenr will superseaeme requirements of this Purchase Order unless signed
by an authorized agent of each	ty subsequent to the date of this Purchase Order.

Page

2   of	2	Coun,y Ma ria>s'"" 1'-

m a d<bum  C ek COO ,n,;m,Ci---

Florida Admin Rule 12A-1.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The COD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD' s Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The CDD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the COD is a paramount consideration. The COD will be deemed to have assumed the risk of loss if the CDD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The COD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE  OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-80157730 53C-0. affirms that the tangible personal property purchased pursuant to Purchase Order Number 190402 from County Materials (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction. Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ad.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule lZA-1.094, F.A.C.:

You must initial each of the following requirements.

4..

The attached Purchase Order is issued directly to the vendor supplying the tangible personal property the Contractor will use in the identified public works.
Th e vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from p funds.
'ti,2::::-4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
purchase or of delivery by the vendor.
'etJs.Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached  Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

1 understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

By:	

Its:  	

C:/..(../.OtY'	_

Fede ral Employer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

You must attach a copy of the Purchase Order to this Certificate of Entitlement.

Do not s end to the Florida De pa r tme nt of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-58

County Materials Corp. P.O.Box435
Astatula, FL 34705

Amount Payable:

$7,268.08

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs ofissuance, if applicable):

Direct purchase of material for construction of Grand Palm, Phase 2A(d). Purchase Order# 190402; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated an1ount  set forth  above have been incurred by the District, that each disbursement set forth above is  a  proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 20I9 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account  that  has  not  previously been paid].

The undersigned hereby further ce1iifies that there has not been filed with or served upon the District notice of any lien, right to lien, or anachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such reqms1t1011 contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to relain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs of Issuance Account or  for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of  the prope11y acquired  or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:	(   �

Authorized Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies  that  this dis burse ment is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set fo1th on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbur se ment is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

w	
Consulting Engineer �

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 2A(d)

    Invoice #		Amount	 149188-18	$3,656.16
   149188-20	$3,611.92	
Sub-Total	$7,268.08

COU N T Y

SHIPPED	IN VO ICE DATE	I		ORDER NO.	
11/14/1 9	11 /14/19	I	149		188 -18	
I	P.O. NO.			I	PAGE#	
44	I ct	190402			I	1 of 1	

(866) 343-8 488 Fax (352) 343-0471

NOV 1 9 2019INVOICE

MATERIALS CORPORATION

ASTATULA, FL 34705-0435

REMIT TO: PO BOX 38

CUST #:	3275	MARATHON, WI 54448 -00 38
Grand Palm Phase 2AD
SHIP rn : Sarasota County
Observation Blvd off Cent er Rd Venice FL 34292

BILL TO :

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNT A GORDA FL 33950

LINE NO.	I	PRODUCT
AND DESCRIPTION	I	QTY. SHIPPED	I	
QTY.
U/M	I	UNIT PRICE	,I	AMOUNT (NET)	
1	218380s	72. 00	LFT	16 . 05 v	1155. 601	
	18" RCP CL3 SMALL BELL				
2	218ep	9. 00	EA	0. 00	0. 00	
	18" RCCP GASKET SMALL BELL				
5	230380s	/	72 . 00	LF	34. 73 /	2500. 56/	
	30" RCP CL3 SMALL BELL				
6	230s	9. 00	EA	0.00	0. 00	
	30" RCCP GASKET SMALL BELL #839230				
			Total	3656. 16	
			Invoice Total	3656. 16	

v

COU NTY

SHIPPED	INVO ICE DATE	I	ORDER NO.	
11/14/19	11/14/19	I	149188-20	
I	P.O . NO.	I	PAGE#	
44	I ct	190402	I 1 of 1	

. (866) 343-8488 Fax (352) 343 -0 4 71

NOV '9	'l 0l9	INVOICE

MATERIALS CORPORATION

ASTA TULA, FL 34705-0435

REMIT TO: PO BOX 38

CUST #:	3275	MARATHON, WI 54448 -00 38
Grand Palm Phase 2AD
SHIP ro : Sarasota County
Observation Blvd off Cent er Rd Venice FL 34292

BILL TO :

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNT A GORDA FL 33950

			;S  i?i;     ED	I
V  104. 00

13.  00	Q TY . I	UNIT
U/M	PRICE
LF	34.  73

EA	0. 00

Total
Invoice Total	I	AMOUNT (NET)
3611 . 92

0 . 00

3611 . 92
3611.92	
LINE I
NO .	PRODUCT
AND DESCRIPTION	I					
5	230380s						
	30" RCP CL3 SMALL BELL						
6	230s						
	30" RCCP GASKET SMALL BELL #839230						

V

PURCHASE ORDER No. 	/90402	

Blackburn Creek
Co1nmunity Develop1nent District
c/ o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 339 50
Phone: (94L) 637 -8500	Fax: (941) 639-1073
Underground Utility License #CUC055716 Visit Us at www.forsbergconsrruction.com

Vendor: County Materials Corporation

Address:   P.O. Box 435	

   Astatula, FL 34705	

Attention: Johnny Smith 941-915-3671

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: ObeNation Blvd off of Center Road Venice, Florida
Legal Desc.:   Sec  19&20,  Twp: 39S,	Range 20E	

County:  Sarasota      	  Payment Terms:  Net 30 days	                                    Vendor Phone: 866-343-8488
Vendor Fax:  352-343-0471	

Quantity	Unit	Description	Unit Price	Total Price	
						
184	+/-	LF	18"RCP	s	16.05		s	2,953.20	
776	+/-	LF	24" RCP	$	24.45		s	18,973 .20	
744	+/-	LF	30" RCP	s	34.73		s	25,839.12	
192	+/-	LF	36" RCP	s	48.53		$	9,317.76	
400	+/-	LF	54"RCP	s	98.03		$	39,212.00	
3	+/-	EA	24 " Flared End Section	s	1,012.00		s	3, 036.00	
2	+/-	EA	30 " Flared End Section	$	1,3 15.40		s	2,630.80	
I	+/-	EA	36• Flared End Section	s	1,562.00		s	, 1 562.00	
I	+/-	EA	54• Flared End Section	$	4,086.70		s	, 4 086 .70	

						
						
		Prices ar e good for duration of the project.				
						
		Project Duration : April I 5, 2019 - April I 5, 2020				
!	Total Project Subtotal	s	107,610.78	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ 1.0 % on 1st $5,000.00	tax exempt	
TOTAL	s	107,6 10.78	

Blackburn Creek COD Chairman

 	-
Authorized Agent /signa tur e}
! IMPORTANT !

Date

Page	 		of	2

,1SEESPECIAL PROVISIONS ABOVE

ADD ITION AL TERMSAND CONDITIONSON PAGE 2

TERMS AND  CONDITIONS
Alf material shall be as specified and warranted in accordance to the Project specifications, plans and addenda. Material shall be within accepted standards for workmanship and quality, and shall be satisfactory to meet approval of the Owner, Owner's representative and Purchase.r

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. Alf items supplied without prior approval, that do not meet Project requirements, will bereturned to Vendor, by Vendor, at no charge to Purchaser.

Time is of the essence.

Delivery of materials to be coordinated by Purchaser in ord er to accommodate unloading. Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the following work day to be unloaded. Purchaser will not beresponsible for any demurrage charge for such hold over.

Should the Vendor fail to provide material as scheduled by Purchaser and Vendor, the Purchaser, upon 3 day written notice to Vendor, shall have the right to procure said materials elsewhere without further responsibility to Vendor.

Quantities are approximate and subject to project requirements.

Vendor agrees to accept without charge to Purchaser, all extra, non-specialty materials in good condition which remain after completion of work and will issue full credit for same.

Vendor shall sign and return Purchase Order within 1O days of Purchase Order date. Purchaser will return an executed Purchase Order to Vendor.

To insure prompt payment, Purchase Order number must appear on all invoices and copies of signed delivery slips attached.

Neith er party will change, alter, nor substitute any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be ini tialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaser without receipt of a properly sign ed and acceptable Purchase Order.

Shipment of any materials, before signing this Purchase Order, will beconsidered an acceptance of this Purchase Ord er.

If Vendor fails to properly execute and return Purchase Order within 1O days, Purchaser may consider offer rejected.

I 5. This agreeme n t shall be governed by the laws of the Stat e of Florida with venue in Charlotte Coun ty, Florida.

16. The authorized agent signing this Purchase Order for the Vendor must be duly authorized to do so on behalf of the Vendor or on behalf of any such disclosed principal.

17.

18 .

In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full force and effect.

This Purchase Order is the only binding contract betw een Purchaser and Vendor for this project and the work

r

described. This Purchase Order replaces all previous contracts and agreements,w heth  er written or  verbal, regaro1ng mis proJecr. No otner aocumenr will superseaeme requirements of this Purchase Order unless signed
by an authorized agent of each	ty subsequent to the date of this Purchase Order.

Page

2   of	2	Coun,y Ma ria>s'"" 1'-

m a d<bum  C ek COO ,n,;m,Ci---

Florida Admin Rule 12A-1.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The COD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD' s Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The CDD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the COD is a paramount consideration. The COD will be deemed to have assumed the risk of loss if the CDD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The COD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE  OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-80157730 53C-0. affirms that the tangible personal property purchased pursuant to Purchase Order Number 190402 from County Materials (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction. Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ad.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule lZA-1.094, F.A.C.:

You must initial each of the following requirements.

4..

The attached Purchase Order is issued directly to the vendor supplying the tangible personal property the Contractor will use in the identified public works.
Th e vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from p funds.
'ti,2::::-4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
purchase or of delivery by the vendor.
'etJs.Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached  Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

1 understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

By:	

Its:  	

C:/..(../.OtY'	_

Fede ral Employer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

You must attach a copy of the Purchase Order to this Certificate of Entitlement.

Do not s end to the Florida De pa r tme nt of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-58

County Materials Corp. P.O.Box435
Astatula, FL 34705

Amount Payable:

$7,268.08

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs ofissuance, if applicable):

Direct purchase of material for construction of Grand Palm, Phase 2A(d). Purchase Order# 190402; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated an1ount  set forth  above have been incurred by the District, that each disbursement set forth above is  a  proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 20I9 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account  that  has  not  previously been paid].

The undersigned hereby further ce1iifies that there has not been filed with or served upon the District notice of any lien, right to lien, or anachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such reqms1t1011 contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to relain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs of Issuance Account or  for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of  the prope11y acquired  or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:	(   �

Authorized Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies  that  this dis burse ment is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set fo1th on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbur se ment is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

w	
Consulting Engineer �

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 2A(d)

    Invoice #		Amount	 149188-18	$3,656.16
   149188-20	$3,611.92	
Sub-Total	$7,268.08

COU N T Y

SHIPPED	IN VO ICE DATE	I		ORDER NO.	
11/14/1 9	11 /14/19	I	149		188 -18	
I	P.O. NO.			I	PAGE#	
44	I ct	190402			I	1 of 1	

(866) 343-8 488 Fax (352) 343-0471

NOV 1 9 2019INVOICE

MATERIALS CORPORATION

ASTATULA, FL 34705-0435

REMIT TO: PO BOX 38

CUST #:	3275	MARATHON, WI 54448 -00 38
Grand Palm Phase 2AD
SHIP rn : Sarasota County
Observation Blvd off Cent er Rd Venice FL 34292

BILL TO :

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNT A GORDA FL 33950

LINE NO.	I	PRODUCT
AND DESCRIPTION	I	QTY. SHIPPED	I	
QTY.
U/M	I	UNIT PRICE	,I	AMOUNT (NET)	
1	218380s	72. 00	LFT	16 . 05 v	1155. 601	
	18" RCP CL3 SMALL BELL				
2	218ep	9. 00	EA	0. 00	0. 00	
	18" RCCP GASKET SMALL BELL				
5	230380s	/	72 . 00	LF	34. 73 /	2500. 56/	
	30" RCP CL3 SMALL BELL				
6	230s	9. 00	EA	0.00	0. 00	
	30" RCCP GASKET SMALL BELL #839230				
			Total	3656. 16	
			Invoice Total	3656. 16	

v

COU NTY

SHIPPED	INVO ICE DATE	I	ORDER NO.	
11/14/19	11/14/19	I	149188-20	
I	P.O . NO.	I	PAGE#	
44	I ct	190402	I 1 of 1	

. (866) 343-8488 Fax (352) 343 -0 4 71

NOV '9	'l 0l9	INVOICE

MATERIALS CORPORATION

ASTA TULA, FL 34705-0435

REMIT TO: PO BOX 38

CUST #:	3275	MARATHON, WI 54448 -00 38
Grand Palm Phase 2AD
SHIP ro : Sarasota County
Observation Blvd off Cent er Rd Venice FL 34292

BILL TO :

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNT A GORDA FL 33950

			;S  i?i;     ED	I
V  104. 00

13.  00	Q TY . I	UNIT
U/M	PRICE
LF	34.  73

EA	0. 00

Total
Invoice Total	I	AMOUNT (NET)
3611 . 92

0 . 00

3611 . 92
3611.92	
LINE I
NO .	PRODUCT
AND DESCRIPTION	I					
5	230380s						
	30" RCP CL3 SMALL BELL						
6	230s						
	30" RCCP GASKET SMALL BELL #839230						

V

PURCHASE ORDER No. 	/90402	

Blackburn Creek
Co1nmunity Develop1nent District
c/ o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 339 50
Phone: (94L) 637 -8500	Fax: (941) 639-1073
Underground Utility License #CUC055716 Visit Us at www.forsbergconsrruction.com

Vendor: County Materials Corporation

Address:   P.O. Box 435	

   Astatula, FL 34705	

Attention: Johnny Smith 941-915-3671

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: ObeNation Blvd off of Center Road Venice, Florida
Legal Desc.:   Sec  19&20,  Twp: 39S,	Range 20E	

County:  Sarasota      	  Payment Terms:  Net 30 days	                                    Vendor Phone: 866-343-8488
Vendor Fax:  352-343-0471	

Quantity	Unit	Description	Unit Price	Total Price	
						
184	+/-	LF	18"RCP	s	16.05		s	2,953.20	
776	+/-	LF	24" RCP	$	24.45		s	18,973 .20	
744	+/-	LF	30" RCP	s	34.73		s	25,839.12	
192	+/-	LF	36" RCP	s	48.53		$	9,317.76	
400	+/-	LF	54"RCP	s	98.03		$	39,212.00	
3	+/-	EA	24 " Flared End Section	s	1,012.00		s	3, 036.00	
2	+/-	EA	30 " Flared End Section	$	1,3 15.40		s	2,630.80	
I	+/-	EA	36• Flared End Section	s	1,562.00		s	, 1 562.00	
I	+/-	EA	54• Flared End Section	$	4,086.70		s	, 4 086 .70	

						
						
		Prices ar e good for duration of the project.				
						
		Project Duration : April I 5, 2019 - April I 5, 2020				
!	Total Project Subtotal	s	107,610.78	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ 1.0 % on 1st $5,000.00	tax exempt	
TOTAL	s	107,6 10.78	

Blackburn Creek COD Chairman

 	-
Authorized Agent /signa tur e}
! IMPORTANT !

Date

Page	 		of	2

,1SEESPECIAL PROVISIONS ABOVE

ADD ITION AL TERMSAND CONDITIONSON PAGE 2

TERMS AND  CONDITIONS
Alf material shall be as specified and warranted in accordance to the Project specifications, plans and addenda. Material shall be within accepted standards for workmanship and quality, and shall be satisfactory to meet approval of the Owner, Owner's representative and Purchase.r

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. Alf items supplied without prior approval, that do not meet Project requirements, will bereturned to Vendor, by Vendor, at no charge to Purchaser.

Time is of the essence.

Delivery of materials to be coordinated by Purchaser in ord er to accommodate unloading. Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the following work day to be unloaded. Purchaser will not beresponsible for any demurrage charge for such hold over.

Should the Vendor fail to provide material as scheduled by Purchaser and Vendor, the Purchaser, upon 3 day written notice to Vendor, shall have the right to procure said materials elsewhere without further responsibility to Vendor.

Quantities are approximate and subject to project requirements.

Vendor agrees to accept without charge to Purchaser, all extra, non-specialty materials in good condition which remain after completion of work and will issue full credit for same.

Vendor shall sign and return Purchase Order within 1O days of Purchase Order date. Purchaser will return an executed Purchase Order to Vendor.

To insure prompt payment, Purchase Order number must appear on all invoices and copies of signed delivery slips attached.

Neith er party will change, alter, nor substitute any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be ini tialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaser without receipt of a properly sign ed and acceptable Purchase Order.

Shipment of any materials, before signing this Purchase Order, will beconsidered an acceptance of this Purchase Ord er.

If Vendor fails to properly execute and return Purchase Order within 1O days, Purchaser may consider offer rejected.

I 5. This agreeme n t shall be governed by the laws of the Stat e of Florida with venue in Charlotte Coun ty, Florida.

16. The authorized agent signing this Purchase Order for the Vendor must be duly authorized to do so on behalf of the Vendor or on behalf of any such disclosed principal.

17.

18 .

In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full force and effect.

This Purchase Order is the only binding contract betw een Purchaser and Vendor for this project and the work

r

described. This Purchase Order replaces all previous contracts and agreements,w heth  er written or  verbal, regaro1ng mis proJecr. No otner aocumenr will superseaeme requirements of this Purchase Order unless signed
by an authorized agent of each	ty subsequent to the date of this Purchase Order.

Page

2   of	2	Coun,y Ma ria>s'"" 1'-

m a d<bum  C ek COO ,n,;m,Ci---

Florida Admin Rule 12A-1.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The COD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD' s Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The CDD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the COD is a paramount consideration. The COD will be deemed to have assumed the risk of loss if the CDD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The COD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE  OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-80157730 53C-0. affirms that the tangible personal property purchased pursuant to Purchase Order Number 190402 from County Materials (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction. Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ad.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule lZA-1.094, F.A.C.:

You must initial each of the following requirements.

4..

The attached Purchase Order is issued directly to the vendor supplying the tangible personal property the Contractor will use in the identified public works.
Th e vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from p funds.
'ti,2::::-4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
purchase or of delivery by the vendor.
'etJs.Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached  Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

1 understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

By:	

Its:  	

C:/..(../.OtY'	_

Fede ral Employer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

You must attach a copy of the Purchase Order to this Certificate of Entitlement.

Do not s end to the Florida De pa r tme nt of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Review of District Financial Statements

Blackburn Creek CDD Statement of Activities As of 11/30/2019

General Fund

Debt Service -	Debt Service -	Debt Service -	Capital Proiects		Capital	Capital Project -	Long Term 2013 & 2019		2015		2018		- 2013 & 2019	Projects - 2015		2018	Debt Group

Total

Revenues																		

On-Roll Assessments	
$8,226.37																
$8,226.37	
On-Roll Assessments			$31,192.53														31,192.53	
Inter-Fund Group Transfers In			(249.97)														(249.97)	
On-Roll Assessments					$26,845.02												26,845.02	
Other Assessments					50,434.71												50,434.71	
On-Roll Assessments							$19,159.80										19,159.80	
Other Assessments							45,259.00										45,259.00	
Inter-Fund Transfers							(26.30)										(26.30)	
Inter-Fund Transfers In									$249.97								249.97	
Inter-Fund Transfers													$26.30				26.30	
Total Revenues	

$8,226.37		

$30,942.56		

$77,279.73		

$64,392.50		

$249.97		$0.00		$26.30		$0.00		$181,117.43	

Expenses																		

Supervisor Fees	
$1,800.00																
$1,800.00	
Insurance	2,423.00																2,423.00	
Trustee Services	3,889.84																3,889.84	
Management	2,083.33																2,083.33	
District Counsel	276.50																276.50	
Assessment Administration	22,500.00																22,500.00	
Legal Advertising	145.75																145.75	
Web Site Maintenance	125.00																125.00	
Dues, Licenses, and Fees	175.00																175.00	
General Insurance	3,499.00																3,499.00	
Capital Expenditure									$68,435.53								68,435.53	
Capital Expenditure													$1,538.68				1,538.68	
Total Expenses	

$36,917.42		

$0.00		

$0.00		

$0.00		

$68,435.53		$0.00		$1,538.68		$0.00		$106,891.63	

Other Revenues (Expenses) & Gains (Losses)																		
Total Other Revenues (Expenses) & Gains (Losses)	$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00	

Change In Net Assets	
($28,691.05)		
$30,942.56		
$77,279.73		
$64,392.50		
($68,185.56)		
$0.00		
($1,512.38)		
$0.00		
$74,225.80	

Net Assets At Beginning Of Year	
$67,522.90		
$707,719.95		
$595,275.08		
$803,405.05		
$2,118,700.26		
$174,345.63		
$379,490.73		
$0.00		
$4,846,459.60	

Net Assets At End Of Year	
$38,831.85		
$738,662.51		
$672,554.81		
$867,797.55		
$2,050,514.70		
$174,345.63		
$377,978.35		
$0.00		
$4,920,685.40	

Debt Service - 2015	Debt Service - 2018	Capital Proiects - 2013 & 2019	Capital Projects - 2015	Capital Project Fund - 2018	Long Term Debt Group	Total	
	
Assets						
						
$116,183.20	
						136,528.63	
						646,614.97	
						31,192.53	
						178,150.00	
						91,674.93	
						274,895.96	
						134.12	
						27,885.24	
						5,039.64	
						89,155.83	
						40,534.26	
$300,373.73						300,373.73	
26,845.02						26,845.02	
233,662.50						233,662.50	
106,406.25						106,406.25	
135,003.87						135,003.87	
18,432.83						18,432.83	
127,178.54						127,178.54	
25,025.80						25,025.80	
	$344,984.77					344,984.77	
	2,562.00					2,562.00	
	172,505.48					172,505.48	
	150,789.00					150,789.00	
	177,796.50					177,796.50	
	19,159.80					19,159.80	
	799,478.20					799,478.20	
		$20,877.74				20,877.74	
		2,106,219.88				2,106,219.88	
			$190,351.78			190,351.78	
				$509,975.49		509,975.49	
$972,928.54	$1,667,275.75	$2,127,097.62	$190,351.78	$509,975.49	$0.00	$7,105,618.49	

Blackburn Creek CDD Statement of Financial Position As of 11/30/2019

General Fund

Debt Service - 2013 & 2019

Current Assets				
General Checking Account Assessments Receivable Assessments Receivable Due From Other Funds
Debt Service Reserve 2013A Bond Debt Service Reserve 2019A Bond Revenue 2013A Bond
Revenue 2019A Bond	$116,183.20
136,528.63			
			$646,614.97 31,192.53
178,150.00
91,674.93
274,895.96
134.12	
Prepayment 2013A Bond Sinking Fund 2013A Bond
Capitalized Interest 2019A1 Bond Capitalized Interest 2019A2 Bond
Assessments Receivable			27,885.24
5,039.64
89,155.83
40,534.26	
Due From Other Funds				
Debt Service Reserve 2015A1 Bond				
Debt Service Reserve 2015A2 Bond				
Revenue 2015A Bond				
Prepayment 2015A1 Bond Prepayment 2015A2 Bond Sinking Fund 2015A1 Bond
Revenue 2018A Bond				
Prepayment 2018A1 Bond
Debt Service Reserve 2018A1 Bond				
Prepayment 2018A2 Bond
Capitalized Interest Account 2018A2 Bond Due From Other Funds				
Assessments Receivable				
Acquisition/Construction 2013A Bond Acquisition/Construction 2019A Bond Acquisition/Construction 2015A Bond Aquisition/Construction 2018A Bond				
Total Current Assets	$252,711.83		$1,385,277.48	

Investments				
Amount Available in Debt Service Funds				
Amount To Be Provided				
Total Investments	$0.00		$0.00	
Total Assets	$252,711.83		$1,385,277.48	

$0.00		

$0.00		

$0.00		

$0.00		

$0.00		$2,201,817.52 23,130,182.48
$25,332,000.00		$2,201,817.52 23,130,182.48
$25,332,000.00	
$972,928.54		$1,667,275.75		$2,127,097.62		$190,351.78		$509,975.49		$25,332,000.00		$32,437,618.49	

Blackburn Creek CDD Statement of Financial Position As of 11/30/2019

Debt Service -	Debt Service -	Debt Service -	Capital Proiects -	Capital	Capital Project	Long Term Debt	
2013 & 2019	2015	2018	2013 & 2019	Projects - 2015	Fund - 2018	Group	

General Fund	Total

Liabilities and Net Assets	

Current Liabilities Accounts Payable Deferred Revenue Deferred Revenue Deferred Revenue Deferred Revenue Retainage Payable Developer Advance Retainage Payable Retainage Payable
Total Current Liabilities	

$77,351.35 136,528.63

$213,879.98		

$646,614.97

$646,614.97		

$300,373.73

$300,373.73		

$799,478.20

$799,478.20		

$62,755.92 13,827.00

$76,582.92		

$16,006.15

$16,006.15		

$131,997.14

$131,997.14		

$0.00		

$77,351.35 136,528.63
646,614.97
300,373.73
799,478.20
62,755.92
13,827.00
16,006.15
131,997.14

$2,184,933.09	

Long Term Liabilities
Revenue Bonds Payable - Long-Term Total Long Term Liabilities

Total Liabilities	

$0.00

$213,879.98		

$0.00

$646,614.97		

$0.00

$300,373.73		

$0.00

$799,478.20		

$0.00

$76,582.92		

$0.00

$16,006.15		

$0.00

$131,997.14		

$25,332,000.00

$25,332,000.00

$25,332,000.00		

$25,332,000.00

$25,332,000.00

$27,516,933.09	

Net Assets
Net Assets, Unrestricted
Current Year Net Assets - General Government

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Total Net Assets

Total Liabilities and Net Assets	

$67,522.90 (28,691.05)

$38,831.85

$252,711.83		

$707,719.95 30,942.56

$738,662.51

$1,385,277.48		

$595,275.08 77,279.73

$672,554.81

$972,928.54		

$803,405.05 64,392.50

$867,797.55

$1,667,275.75		

$2,118,700.26 (68,185.56)

$2,050,514.70

$2,127,097.62		

$174,345.63
0.00

$174,345.63

$190,351.78		

$379,490.73 (1,512.38)

$377,978.35

$509,975.49		

$0.00

$25,332,000.00		

$67,522.90 (28,691.05)

707,719.95
30,942.56

595,275.08
77,279.73

803,405.05
64,392.50

2,118,700.26
(68,185.56)

174,345.63
0.00

379,490.73
(1,512.38)

$4,920,685.40

$32,437,618.49	

Blackburn Creek CDD
Budget to Actual
For the Month Ending 11/30/2019	
Year To Date	
		
Actual			
Budget			
Variance	FY 2020
Adopted Budget	

Revenues												
On-Roll Assessments
Net Revenues	$	8,226.37

$	8,226.37		$
$	24,125.83
24,125.83		$
$	(15,899.46)
(15,899.46)	$	144,755.00

$	144,755.00	
General & Administrative Expenses
Supervisor Fees
Public Officials' Insurance Trustee Services Management  Engineering Dissemination Agent District Counsel
Assessment Administration Reamortization Schedules Audit
Arbitrage Calculation Telephone
Postage & Shipping Copies
Legal Advertising Office Supplies
Web Site Maintenance Dues, Licenses, and Fees Stormwater Management General Insurance
General Repair & Maintenance
Total General & Administrative Expenses	

$	1,800.00
2,423.00
3,889.84
2,083.33
-
- 276.50
22,500.00
-
-
-
-
-
- 145.75
- 125.00
175.00
- 3,499.00
-

$	36,917.42	

$	2,000.00
433.33
2,666.67
4,166.67
1,666.67
1,666.67
3,333.33
2,500.00
166.67
750.00
166.67
33.33
75.00
25.00
833.33
33.33
450.00
33.33
1,666.67
625.83
833.33

$	24,125.83		

$

$	

(200.00)
1,989.67
1,223.17
(2,083.34)
(1,666.67)
(1,666.67)
(3,056.83)
20,000.00
(166.67)
(750.00)
(166.67)
(33.33)
(75.00)
(25.00)
(687.58)
(33.33)
(325.00)
141.67
(1,666.67)
2,873.17
(833.33)
12,791.59	

$	12,000.00
2,600.00
16,000.00
25,000.00
10,000.00
10,000.00
20,000.00
15,000.00
1,000.00
4,500.00
1,000.00
200.00
450.00
150.00
5,000.00
200.00
2,700.00
200.00
10,000.00
3,755.00
5,000.00

$	144,755.00	

Total Expenses	
  $	36,917.42	
   $	24,125.83		
  $		
12,791.59	
  $	144,755.00	
Income (Loss) from Operations	$	(28,691.05)		$	-		$	(28,691.05)		$	-	
Net Income (Loss)	$	(28,691.05)		$	-		$	(28,691.05)		$	-