2023A-12569-OMC-LS-ROC Notice of Hearing & Packet MAILED

2023A-12569-OMC-LS-ROC · Registrar of Contractors · 2024-10-21

REGISTRAR OF CONTRACTORS OF THE STATE OF ARIZONA

Arizona Registrar of Contractors Case No. 2023-12569 COMPLAINANT, Docket No. 2023A-12569-OMC-LS- v. ROC CQH CONTRACTING LLC NOTICE OF HEARING ON License No. ROC 338678, CONTESTED CASE

RESPONDENT.

This Notice of Hearing is issued under A.R.S. § 41-1092.05(D). HEARING INFORMATION The hearing is set for:

December 6, 2024 9:00 AM Kay Abramsohn Google Meet. A link will be provided directly from The Office of Administrative Hearings. Go to www.azoah.com to request to appear in-person.

If you have requested to appear in-person at the hearing, the hearing will be held at 1740 W Adams Street, Phoenix, AZ 85007.

You must attend this hearing. This is an adversarial hearing before an administrative

law judge, and is conducted in a similar manner as judicial proceedings. Thus, you must be

prepared to present evidence, including witness testimony and documents, in support of your case.

STATEMENT OF LEGAL AUTHORITY AND JURISDICTION

The State of Arizona has determined that the licensing and regulation of construction contractors is a proper state function, and has vested authority in the Registrar of Contractors to administer Title 32, Chapter 10 of the Arizona Revised Statutes. A.R.S. §§ 32-1101 et seq. All hearings for alleged violations of Title 32, Chapter 10 are conducted under Title 41,

Chapter 6, Article 10. A.R.S. § 32-1156.

The statutes and rules governing the hearing can be found at: Arizona Revised

Statutes §§ 41-1092 to -1092.12, and Arizona Administrative Code R2-19-101 to -122.

PARTICULAR ARIZONA STATUTES AND RULES INVOLVED

The statutes and rules the Respondent is alleged to have violated are cited in the

complaint and citation, which were served on the Respondent on September 24, 2024. SHORT AND PLAIN STATEMENT OF THE MATTERS ASSERTED

The complaint and citation allege that the Respondent committed the following act(s): Charge: 1 A.R.S. § 32-1154(A) (4) Charge: 2 A.R.S. § 32-1154(A)(9)

Charge: 3 A.R.S. § 32-1154(A) (12) § 32-1124(B)(1)

THE PARTIES TO THE ADMINISTRATIVE HEARING Because Respondent is a licensee and is charged with an act(s) or omission(s) that is cause for the suspension or revocation of a license, Respondent is a party to this case and will be a party to the hearing. Because Complainant alleged Respondent committed an act(s) or omission(s) that is cause for the suspension or revocation of a license, Complainant is a party to this case and will

be a party to the hearing.

Respondent and Complainant, as the parties to the hearing, will present evidence and

argument to the administrative law judge.

RIGHT TO BE REPRESENTED The parties to the administrative hearing may choose to be represented by an attorney. A.R.S. § 41-1092.07(B). If one of the parties is a company, the company may be represented

by an officer or employee if that person satisfies the conditions set forth in A.R.S. § 32-

1156(B).

CHANGE OF ADDRESS Each party must inform the Registrar and the Office of Administrative Hearings of any change of address within five (5) days of the change. A.R.S. § 41-1092.04.

HEARING PROCEDURES AND RULES

The administrative hearing will be conducted in accordance with A.R.S. §§ 41-1092 to -1092.12, and A.A.C. R2-19-101 to -122. The parties should review the statutes, rules, and

processes governing the administrative hearing. Copies of the statutes, rules, and articles regarding the administrative hearing process can be found at https://www.azoah.com/.

REGISTRAR’S APPEARANCE BY VIDEO CONFERENCE OR TELEPHONE

The Registrar’s investigators, employees, and attorneys will appear at the hearing via

video conference or telephone unless requested by a party to appear in-person. Requests for the Registrar’s investigators, employees, or attorneys to appear in-person must be filed with the Registrar and the Office of Administrative Hearings no later than seven (7) calendar days prior to the hearing date.

HEARING PACKET

In the interests of administrative efficiency, the Registrar compiles and discloses

certain documents to the parties and the Office of Administrative Hearings. These documents

are attached to this Notice of Hearing as the “Hearing Packet.” If any party wishes to submit additional evidence, they must do so during the hearing after completing a disclosure statement. See “Disclosure Statement” section below.

SUBPOENAS FOR TESTIMONY FROM A WITNESS OR DOCUMENTS

The parties to the hearing must be prepared to present evidence in support of their

case. If a party wants to obtain testimony from a witness or documents not in the party’s

possession, the party must prepare and file a written subpoena for the Administrative Law

Judge to review and sign, if approved. A.R.S. § 41-1092.07(C). Forms for requesting a subpoena can be found on the Office of Administrative Hearings’ website at www.azoah.com.

The party seeking a subpoena must serve notice on all the parties to the hearing, and on the Registrar. A.R.S. § 41-1092.04.

DISCLOSURE STATEMENT

At least seven calendar days before the hearing, each party must prepare and serve a

disclosure statement on all other parties, and file it with the Office of Administrative Hearings. A.A.C. R4-9-118; A.A.C. R2-19-108. The disclosure statement must include any exhibit the party will use at the hearing. A party’s failure to timely disclose any witness or exhibit, without good cause, may result in the administrative law judge excluding those witnesses or exhibits from being used at the hearing. A.A.C. R4-9-118(C). A sample disclosure form is available on the Registrar’s website at https://roc.az.gov/forms/RC-L-800A%20- %20Prehearing%20Disclosure%20Statement%2020191007v4.pdf

CHANGING THE HEARING DATE

The date of the hearing may only be advanced or delayed on the agreement of the

parties or on a showing of good cause. A.R.S. § 41-1092.05(C). The date of the hearing may

be changed by filing a written agreement of the parties to change the date of the hearing. The

written agreement must be filed with the Office of Administrative Hearings, directed to the assigned Administrative Law Judge, and transmitted to the Registrar and all other parties. The assigned Administrative Law Judge may be found on the Office of Administrative Hearings’ web portal at www.azoah.com

If a party would like to move the date of the hearing without agreement of all parties, the party must file a written motion with the Office of Administrative Hearings, directed to the assigned Administrative Law Judge, and transmit a copy to the Registrar and all other parties. The motion must state in detail good cause for why the date of the hearing should be advanced or delayed, and the position of all other parties regarding the advancement or delay. A party may also file a motion asserting a right to an expedited hearing upon a showing of

extraordinary circumstances or the possibility of irreparable harm. A.R.S. § 41-1092.05(E).

RESOLUTION SHORT OF ADJUDICATION In any case which is resolved or settled by the parties, or which is withdrawn by the Complainant without objection from Respondent after the Notice of Hearing is issued, the parties must notify the Office of Administrative Hearings of the resolution or settlement. Any such cases will be listed on the Registrar’s website and its records under the category: “Closed

Complaints – Resolved/Settled/Withdrawn.”

Dated October 21, 2024.

By: /s/ Erika Hoskin Erika Hoskin Legal Assistant II Legal Department Arizona Registrar of Contractors

Copy mailed via USPS First Class mail October 21, 2024 to:

Respondent(s) CQH CONTRACTING LLC 5121 N Mission Ln Prescott Valley, AZ 86314

Complainant(s) Arizona Registrar of Contractors 1700 W Washington St Ste. 105 Phoenix, AZ 85007 Registrar’s Counsel Charles Hover III 2005 N Central Ave Phoenix, AZ 85004 Copy sent electronically this same date to: Respondent at email address on record with the Registrar Registrar’s Counsel Charles Hover III Esq., Assistant Attorney General Case No. 2023-12569 /

Hearing Packet FAQ What is the The Hearing Packet is a packet of certain documents collected or Hearing Packet? issued by the Registrar over the course of its investigation. Who gets the The Hearing Packet is assembled and distributed to all parties and Hearing Packet? to the Office of Administrative Hearings (“OAH”) prior to an administrative hearing. What types of The Registrar prepares a Hearing Packet for Complainant-Handled cases does the Cases and No-Pay Cases. Note: If the Docket Number on the Registrar prepare a Notice of Hearing contains a “CHC” or “NPC”, your case is a Hearing Packet for? Complainant-Handled Case or a No-Pay Case. What is in the The Hearing Packet contains essential case-specific documents and Hearing Packet? at a minimum will include the following documents: ● Original complaint; ● Citation; and ● Answer. The Hearing Packet will also contain the following documents (if applicable): ● Jobsite inspection notices, notes, and photos; ● Written directives; and ● Compliance inspection notices, notes, and photos. What if there are If there is any evidence you submitted to the Registrar that are not documents missing included in the Hearing Packet it is your responsibility to introduce from the Hearing that evidence at the administrative hearing. Note: The Packet? administrative law judge assigned to your case does not have access to the entire Registrar record.

If there is additional evidence you submitted to the Registrar during the investigation that you also want to introduce as evidence during your hearing, it is your responsibility to: ● Properly disclose that evidence to the other party; and ● Introduce the evidence during your hearing.

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Within AZ 877.692.9762 · Fax 602.542.1599 · roc.az.gov Hearing Packet FAQ

How do I disclose You must properly disclose any and all documents and witnesses evidence I intend to you intend to use at your hearing according to the Registrar’s use at a Hearing? Prehearing Disclosure Rules. See Arizona Administrative Code Section R4-9-118. A sample prehearing disclosure form and instructions are provided to the parties by the Registrar. How do I obtain If you previously submitted documents to the Registrar and need a documents I copy of these documents, please contact the Registrar’s Legal previously submitted Department or submit a public records request at to the Registrar? https://roc.force.com/AZRoc/s/roc-public-request.

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Within AZ 877.692.9762 · Fax 602.542.1599 · roc.az.gov Hearing Packet FAQ

1/8/24, 4:37 PM State of Arizona Mail - 2024-00106 Carroll

James Dimond <[email redacted]>

2024-00106 Carroll James Dimond <[email redacted]> Thu, Jan 4, 2024 at 4:13 PM To: [email redacted]

Mr. Fortune,

I attempted to contact you by phone but your mailbox is full.

I have already sent you this complaint but have some questions.

In reviewing the permit information I notice that Clyde Neville is named in numerous places on the permit. Please advise what Clyde's relationship is with the company as he appears to be claiming to be GC Consultant's.

Two building officials have also informed me of 2 other of your projects that the same apparent relationship occurs.

Randy Istine also appears on permit documents for those jobs.

Please advise as to what Randy Istine's relationship is with your company.

The other addresses in question are 9760 Towago in PV and 833 N. Cochise in Prescott Country Club.

Your cooperation and prompt reply are appreciated.

Regards,

Image result for arizona registrar of contractors seal ROC Logo/ To ROC Home Page ROC Investigator Badge/ Link to Investigations menu cid:[email protected] cid:[email protected]

https://mail.google.com/mail/u/0/?ik=6fd2afdf83&view=pt&search=all&permmsgid=msg-a:r1502741238984653933&simpl=msg-a:r1502741238984653… 1/2 1/8/24, 4:37 PM State of Arizona Mail - 2024-00106 Carroll

It is too late, when told to evacuate! BE FIREWISE!!! : www.regionalinfo-alert.org

Fill out AZ ROC’s survey to let us know how we’re

doing and how we can better serve you!

cid:[email protected]

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https://mail.google.com/mail/u/0/?ik=6fd2afdf83&view=pt&search=all&permmsgid=msg-a:r1502741238984653933&simpl=msg-a:r1502741238984653… 2/2 Complainant: Arizona Registrar of Contractors 1700 W Washington St Ste 105 Phoenix, AZ 85007

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013c 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013c 04/21 January 8, 2024

WARNING LETTER

Re: Complaint No. 2023-12569; License No. ROC 338678

Dear Respondent:

The Registrar believes that necessary building permits were not obtained for a project located at: 9760 Towago, Prescott Valley, AZ, 86314

(a) Under A.R.S. § 32-1154(A)(2), a licensee may not depart from or disregard: Plans or specifications in any material respect that is prejudicial to another without consent of owner or the owner’s duly authorized representative and without the consent of the person entitled to have the particular construction project or operation completed in accordance with such plans and specifications and code; or

(b) A building code of the state or any political subdivision of this state in any material respect that is prejudicial to another.

Additionally, the International Residential Code and the International Building Code Chapter 1, Sections R105 and 105, state:

Any owner or authorized agent who intends to construct, enlarge, alter, repair, move, demolish or change the occupancy of a building or structure, or to erect, install, enlarge, alter, repair, remove, convert or replace any electrical, gas, mechanical or plumbing system, the installation of which is regulated by this code, or to cause any such work to be done, shall first make application to the building official and obtain the required permit.

Additionally, A.R.S. § 32-1154(A)(2) includes grounds for suspension or revocation of a contractor’s license:

Departure from or disregard of plans or specifications or any building codes of the state or any political subdivision of the state in any material respect that is prejudicial to another without consent of the owner or the owner’s duly authorized representative and without the consent of the person entitled to have the particular construction

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013c 04/21 project or operation completed in accordance with such plans and specifications and code. (Emphasis added.)

A violation of A.R.S. § 32-1154(A)(2) would constitute grounds to suspend or revoke your license. Please review A.R.S. § 32-1154(A)(2), the International Residential Code, and the International Building Code to make sure you are complying with their requirements.

Sincerely,

/s/ Jim Dimond #170 Jim Dimond #170, Investigator 1700 W. Washington St., Suite 105/Yavapai County Phoenix, Arizona, 85007 Phone: (602)542-1525 Office: (928)637-1463 Cell: (623)680-9585 Email: [email redacted]

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013c 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013e 04/21 January 8, 2024

WARNING LETTER

Re: Complaint No. 2023-12569; License No. ROC 338678

Dear Respondent:

It appears that you may have violated A.R.S. § 32-1124(B). Your jobsite at 833 Cochise, Dewey, AZ, 86327 does not include your license number preceded by the acronym “ROC.”

Section 32-1124(B) requires that your license number, preceded by the acronym “ROC,” be placed conspicuously on the premises where you perform work. That statute also requires that you place your license number, preceded by the acronym “ROC,” on all:

written bids submitted by Respondent; broadcast, published, internet, and billboard advertising; and letterheads and any other documents used to correspond with customers or potential customers.

A failure to comply with A.R.S. § 32-1124(B) violates § 32-1154(A)(12), and that violation can constitute grounds to suspend or revoke your license. You need to review A.R.S. § 32-1124(B) and make sure you are complying with its requirements.

Sincerely,

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013e 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013e 04/21 January 8, 2024

WARNING LETTER

Re: Complaint No. 2023-12569; License No. ROC 338678

Dear Respondent:

It appears that you may have violated A.R.S. § 32-1124(B). Your jobsite at 9760 Towago, Prescott Valley, AZ, 86315 does not include your license number preceded by the acronym “ROC.”

written bids submitted by Respondent; broadcast, published, internet, and billboard advertising; and letterheads and any other documents used to correspond with customers or potential customers.

Sincerely,

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013e 04/21 Complainant: Arizona Registrar of Contractors Arizona Registrar of Contractors 1700 W Washington St Ste 105 Phoenix, AZ 85007

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013b 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013b 04/21 March 1, 2024

WARNING LETTER

Re: Complaint No. 2023-12569; License No. ROC 338678

Dear Respondent:

The Registrar received information indicating that you may be contracting with an unlicensed person named RANDALL LAROI INSTINE. Contracting with an unlicensed person is a violation of A.R.S. §§ 32-1154(A)(9) and (13)

A.R.S. § 32-1154(A)(9) states:

Attempting to evade this chapter by:

(a) Aiding or abetting a licensed or unlicensed person.

(b) Acting or conspiring with a licensed or unlicensed person.

(d) Acting as agent, partner, associate or otherwise of a licensed or unlicensed person with intent to evade this chapter.

Violations of either A.R.S. § 32-1154(A)(9) or (13), if proved, would constitute grounds to suspend or revoke your license. Additionally, aiding and abetting an unlicensed person is a class 1 misdemeanor. A.R.S. § 32-1164(A)(1).

If you have any questions, feel free to contact me.

Sincerely,

/s/ Jim Dimond #170 Jim Dimond #170, Investigator 1700 W. Washington St., Suite 105/Yavapai County Phoenix, Arizona, 85007 Phone: (602)542-1525

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013b 04/21 Office: (928)637-1463 Cell: (623)680-9585 Email: [email redacted]

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013b 04/21 Complainant: Arizona Registrar of Contractors Arizona Registrar of Contractors 1700 W Washington St Ste 105 Phoenix, AZ 85007

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013b 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013b 04/21 March 1, 2024

WARNING LETTER

Re: Complaint No. 2023-12569; License No. ROC 338678

Dear Respondent:

The Registrar received information indicating that you may be contracting with an unlicensed person named CLYDE RUSSELL NEVILLE. Contracting with an unlicensed person is a violation of A.R.S. §§ 32-1154(A)(9) and (13)

A.R.S. § 32-1154(A)(9) states:

Attempting to evade this chapter by:

(a) Aiding or abetting a licensed or unlicensed person.

(b) Acting or conspiring with a licensed or unlicensed person.

(d) Acting as agent, partner, associate or otherwise of a licensed or unlicensed person with intent to evade this chapter.

If you have any questions, feel free to contact me.

Sincerely,

/s/ Jim Dimond #170 Jim Dimond #170, Investigator 1700 W. Washington St., Suite 105/Yavapai County Phoenix, Arizona, 85007 Phone: (602)542-1525 Office: (928)637-1463

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013b 04/21 Cell: (623)680-9585 Email: [email redacted]

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013b 04/21 3/1/24, 3:28 PM Workers Compensation Coverage Verification

Industrial Commission Of Arizona LOGIN

Employer FEIN Address

State *

Arizona

Coverage Date *

03/01/2024

Employer Name *

Clyde Russell Neville

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Confirm the spelling of the Employer Address. Suite Numbers may be entered in Address Line 2. Address Search accepts partial addresses.

Not able to find the information required? This does not necessarily mean that coverage does not exist. For additional help with verifying workers' compensation coverage in Arizona, contact the ICA at 602-542-4661.

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Limitation of Information

Information contained in/provided from this database is a representative reflection of selected information

maintained by the Industrial Commission of Arizona and is used for specific workers compensation coverage verification. There may be discrepancies in information provided due to causes outside the control of the Industrial Commission of Arizona such as reporting/recording delays or inaccuracies. Information on self-insured employers

are not included in this database. Any questions for the Industrial Commission of Arizona may be directed to (602) 542-6713 or WWW.ICA.STATE.AZ.US.

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03/01/2024

Employer Name *

CQH Contracting LLC

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are not included in this database. Any questions for the Industrial Commission of Arizona may be directed to (602) 542-6713 or WWW.ICA.STATE.AZ.US.

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Employer FEIN Address

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David Paul Schlax

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are not included in this database. Any questions for the Industrial Commission of Arizona may be directed to (602) 542-6713 or WWW.ICA.STATE.AZ.US.

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03/01/2024

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Gary Fortune

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are not included in this database. Any questions for the Industrial Commission of Arizona may be directed to (602) 542-6713 or WWW.ICA.STATE.AZ.US.

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Randall Laroi Instine

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https://www.ewccv.com/cvs/search?ref=https://www.azica.gov/ 2/2  PERMIT PROJECT  FILE #: 22-008728 7285 W CLARE ISLAND DR KIRKLAND AZ 86332 205-17-245: 24' X 36' DETACHED GARAGE WITH ELECTRIC: SUP23-000409 TO RES22-002228 TO CHANGE FROM CMU TO MONOLITHIC AND TRUSS DIRECTION

       

PERMIT #: RES22-002228

 Permit Type Residential Building Permit Application Subtype New Accessory Structure Work Description: 24' X 36' DETACHED GARAGE WITH ELECTRIC Applicant GC CONSULTANTS - Clyde Neville  Status Issued Valuation 34,560.00 

FEES & PAYMENTS

 Plan Check Fees 0.00 Permit Fees 1,040.71 Total Amount 1,040.71 Amount Paid 1,040.71 Balance Due 0.00 Non-Billable

PERMIT DATES

 Application Date 06/23/2022 Approval Date 09/27/2022 Issue Date: 12/02/2022 Expiration Date: 06/18/2024 Close Date

Last Inspection 1000 FOOTINGS AND STEEL on 12/18/2023 (Failed)  CONSTRUCTION INFORMATION Construction Type Detached garage

PERMIT INFORMATION

Estimated.Cost.of.Construction $30,000.00 Will a construction storage box be used to store construction materials and tools during construction?

Directions to Site

CONTRACTOR INFORMATION

Is Owner using a Contractor Yes Is Contractor currently licensed under provisions of ARS 32-1169? Yes Contractor CQH Contracting LLC - Gary Fortune  Is Project being done as Owner Builder? No Property Owner CARROLL THOMAS P & LAURA J RS  Property Owner Email [email redacted],[email redacted] Property Owner Phone Number 623-414-0646 Microsoft Teams Screen Name

Applicant Signature signature.png 

LIGHTING INFORMATION

Parcels larger than 1 acre are allowed 20,000 shielded lumens. Parcels between 1/2 and 1 acre are allowed 10,000 shielded lumens. Parcels less than 1/2 acre are allowed 7,500 shield lumens.

Parcel Size (net acres or square feet) 1.13  Remaining allowable lumens for this parcel

I attest to the above statement

EXISTING LIGHTING

QUANTITY LOCATION WATTAGE TYPE OF FIXTURE INDIVIDUAL TOTAL BULB LUMENS LUMENS

 TYPE OF INDIVIDUAL TOTAL QUANTITY LOCATION WATTAGE FIXTURE BULB LUMENS LUMENS



 Add Row

NEW LIGHTING

TYPE OF INDIVIDUAL TOTAL QUANTITY LOCATION WATTAGE FIXTURE BULB LUMENS LUMENS

PORCHES & GAR 100 incadasent Shielde 1600 6400.0 



 Add Row

Installer  Designing Engineer GC CONSULTANTS - Clyde Neville  Designer GC CONSULTANTS - Clyde Neville  Architect GC CONSULTANTS - Clyde Neville  ATTACHMENTS

PLEASE PROVIDE A PLOT PLAN, DRAWN TO SCALE, PER THE CHECK LIST; A DIRECTIONS TO SITE MAP; AND ANY ADDITIONAL INFORMATION, INCLUDING PLANS, THAT IS REQUIRED FOR YOUR PARTICULAR TYPE OF PERMIT. ADDITIONAL APPLICATION FORMS/PERMITS MAY BE REQUIRED FROM OTHER UNITS, DEPARTMENTS, OR AGENCIES.

Plot Plan plot 20 24x36.pdf   plot 40 8x11.pdf   plot 40 8x11.pdf   plot 40 8x11.pdf  

Directions to Site site directions.pdf   site directions.pdf   site directions.pdf   site directions.pdf  

Construction Plans

 Floor Plan (MFH)

Geotechnical Report

Engineer's Calculations

Truss Calculations/Layout Floor Calculations/Layout

Manufacturer's Specifications

HVAC Load Calculations/Layout

Special Structural Inspection Certificate

Miscellaneous redline corrections.pdf   redline corrections garage.pdf  

RESIDENTIAL VALUATIONS

VALUATION TYPE SQ.FT.

Garage/Workshop - Wood or Metal 864 

Electrical - New Construction or Additions 864 



 Add Row

MANAL VALUATION CALCULATIONS

Manual Valuation

 Valuation Comments/calculations

OFFICE USE ONLY

Calculate Inspection Fees on Calculated Valuation Document Fee Level 2 Work Without a Valid Permit Fee

Home of My Own

 FEES  FEE DESCRIPTION TOTAL

Inspection Fee 488.31 Plan Review Fee 317.40

Residential Remodel/Addition 100.00 Deposit

Credit - Deposit -100.00 TOTAL

Level 2 Document Fee 20.00

BS Plan Review Fee Additional 2 hr plan review fee 130.00 

Detached Accessory Structures & A 85.00 

Plan Check Fees 0.00

Permit Fees 1,040.71 Total Fees 1,040.71

 PAYMENTS

DATE RECEIVED FROM AMOUNT

07/12/2022 GC CONSULTANTS - Clyde Neville 100.00 

12/02/2022 GC CONSULTANTS - Clyde Neville 940.71 

Amount Paid 1,040.71

Balance Due 0.00  PERMIT PROJECT  FILE #: 22-008733 7285 W CLARE ISLAND DR KIRKLAND AZ 86332 205-17-245: 10' X 11' FRONT AND 11' X 30' REAR PATIOS COVERS FOR MANUFACTURED HOME

       

PERMIT #: RES22-002229

 Permit Type Residential Building Permit Application Subtype Attached Addition, Remodel or Alteration Work Description: 10' X 11' FRONT AND 11' X 30' REAR PATIOS COVERS FOR MANUFACTURED HOME Applicant GC CONSULTANTS - Clyde Neville  Status Issued Valuation 5,280.00 

FEES & PAYMENTS

 Plan Check Fees 0.00 Permit Fees 491.47 Total Amount 491.47 Amount Paid 491.47 Balance Due 0.00 Non-Billable

PERMIT DATES

 Application Date 06/23/2022 Approval Date 12/21/2022 Issue Date: 03/29/2023 Expiration Date: 03/22/2024 Close Date

Last Inspection 1000 FOOTINGS AND STEEL on 09/22/2023 (Passed)  CONSTRUCTION INFORMATION Construction Type Patio - Covered or Uncovered

PERMIT INFORMATION

Estimated.Cost.of.Construction $20,000.00

Directions to Site

CONTRACTOR INFORMATION

Applicant Signature signature.png 

LIGHTING INFORMATION

Parcels larger than 1 acre are allowed 20,000 shielded lumens. Parcels between 1/2 and 1 acre are allowed 10,000 shielded lumens. Parcels less than 1/2 acre are allowed 7,500 shield lumens.

Parcel Size (net acres or square feet) 1.13  Remaining allowable lumens for this parcel

I attest to the above statement

EXISTING LIGHTING

TYPE OF INDIVIDUAL TOTAL QUANTITY LOCATION WATTAGE FIXTURE BULB LUMENS LUMENS

front & back porc 100 INCON Shielde 1600 3200.0 

 TYPE OF INDIVIDUAL TOTAL QUANTITY LOCATION WATTAGE FIXTURE BULB LUMENS LUMENS  Add Row

NEW LIGHTING

TYPE OF INDIVIDUAL TOTAL QUANTITY LOCATION WATTAGE BULB FIXTURE LUMENS LUMENS



 Add Row

Installer  Designing Engineer GC CONSULTANTS - Clyde Neville  Designer GC CONSULTANTS - Clyde Neville  Architect GC CONSULTANTS - Clyde Neville  ATTACHMENTS

Plot Plan

Directions to Site site directions.pdf   site directions.pdf   site directions.pdf   site directions.pdf   site directions.pdf  

Construction Plans red line corrections 12-19-22.pdf  

 Floor Plan (MFH) floor & elevations 8x11.pdf   floor & elevations 8x11.pdf  

Geotechnical Report

Engineer's Calculations

Truss Calculations/Layout

Floor Calculations/Layout

Manufacturer's Specifications HVAC Load Calculations/Layout

Special Structural Inspection Certificate

Miscellaneous red line corrections patios.pdf   red line corrections patios.pdf   corrections 9-28-22.pdf   red line corrections 9-28-22.pdf   RED LINE CORRCTION NOTES.docx  red line corrections 11-29-22.pdf   state appr. screen wall.pdf  

RESIDENTIAL VALUATIONS

VALUATION TYPE SQ.FT.

Covered Patio at Grade Level 330 

Covered Patio at Grade Level 110 

  Add Row

MANAL VALUATION CALCULATIONS

Manual Valuation

 Valuation Comments/calculations

OFFICE USE ONLY

Calculate Inspection Fees on Calculated Valuation Document Fee Level 2 Work Without a Valid Permit Fee

Home of My Own

 FEES  FEE DESCRIPTION TOTAL

Inspection Fee 103.92

Plan Review Fee 67.55 Residential Remodel/Addition 75.00 Deposit TOTAL

Credit - Deposit -75.00

Level 2 Document Fee 20.00

BS Plan Review Fee ADDTIONAL REVIEWS FOR CORRECTIONS 195.00  NOT ADDRESSED

Additions/Enclosure to Primary Dwe 105.00 

Plan Check Fees 0.00

Permit Fees 491.47

Total Fees 491.47

 PAYMENTS

DATE RECEIVED FROM AMOUNT

07/12/2022 GC CONSULTANTS - Clyde Neville 75.00 

03/29/2023 GC CONSULTANTS - Clyde Neville 416.47 

Amount Paid 491.47

Balance Due 0.00  PERMIT PROJECT  FILE #: 24-000306 1129 N TURQUOISE DR PRESCOTT AZ 86303 103-13-090: SINGLE FAMILY RESIDENCE 3 BEDROOM, 2 STORY. SITE BUILT.

       

PERMIT #: RES24-000074

 Permit Type Residential Building Permit Application Subtype New Residence Work Description: SINGLE FAMILY RESIDENCE 3 BEDROOM, 2 STORY. SITE BUILT. Applicant GC CONSULTANTS - Clyde Neville  Status Under Review Valuation 0.00

FEES & PAYMENTS

 Plan Check Fees 0.00 Permit Fees 400.00 Total Amount 400.00 Amount Paid 400.00 Balance Due 0.00 Non-Billable

PERMIT DATES

 Application Date 01/09/2024 Approval Date

Issue Date:

Expiration Date:

Close Date

Last Inspection CONSTRUCTION INFORMATION Construction Type New Residence - Detached Is new dwelling connecting to a sewer system? No Has the onsite wastewater system permit application been submitted? Yes Is the property one acre or larger? No

PERMIT INFORMATION

Estimated.Cost.of.Construction $100,000.00 Will a construction storage box be used to store construction materials and tools during construction?

Directions to Site

CONTRACTOR INFORMATION Is Owner using a Contractor Yes Is Contractor currently licensed under provisions of ARS 32-1169? Yes Contractor CQH Contracting LLC - Gary Fortune  Is Project being done as Owner Builder? No Property Owner - Kolten Collier  Property Owner Email [email redacted] Property Owner Phone Number [number redacted] Microsoft Teams Screen Name

Applicant Signature signature.png 

LIGHTING INFORMATION

Parcels larger than 1 acre are allowed 20,000 shielded lumens. Parcels between 1/2 and 1 acre are allowed 10,000 shielded lumens. Parcels less than 1/2 acre are allowed 7,500 shield lumens.

Parcel Size (net acres or square feet) .47  Remaining allowable lumens for this parcel 1200 I attest to the above statement EXISTING LIGHTING

TYPE OF INDIVIDUAL TOTAL QUANTITY LOCATION WATTAGE FIXTURE BULB LUMENS LUMENS

0.0 



 Add Row

NEW LIGHTING

TYPE OF INDIVIDUAL TOTAL QUANTITY LOCATION WATTAGE FIXTURE BULB LUMENS LUMENS

PORCHES 100 INC Shielded 1600 3200.0 



 Add Row

Installer  Designing Engineer  Designer GC CONSULTANTS - Clyde Neville  Architect  ATTACHMENTS

Plot Plan site 20.pdf   Kolten plot40 8x11.pdf  

Directions to Site site directions, 1129 Turquoise Dr..pdf  

Construction Plans site 20.pdf   general notes.pdf   bld.elements & fasteners.pdf   first & second floor.pdf   foundation.pdf   CAPITAL floor placement 24x36.pdf   CAPITAL DETAILS.pdf   roof framing.pdf   electrical.pdf   decks & section detail.pdf   elevations.pdf   cross section.pdf   M1.01 HVAC LAYOUT first floor.pdf   M1.02 HVAC second floor.pdf   first floor SW STAMPED.pdf   second floor SW STAMPED.pdf  

 Floor Plan (MFH)

Geotechnical Report COLLIER GEO TECH 7 PGS..pdf   COLLIER 14 PGS..pdf  

Engineer's Calculations COLLIER SHEAR WALL STAMPED 8 pgs..pdf  

Truss Calculations/Layout WESTERN TRUSS layout.pdf   WESTERN TRUSS specs 8 pgs..pdf  

Floor Calculations/Layout CAPITAL floor calcs 14 pages.pdf  

Manufacturer's Specifications

HVAC Load Calculations/Layout HVAC calcs, Collier 14 pages.pdf   DUCT SYSTEM Manual D Packet.pdf  

Special Structural Inspection Certificate

Miscellaneous

RESIDENTIAL VALUATIONS

VALUATION TYPE SQ.FT.

  Add Row

MANAL VALUATION CALCULATIONS

Manual Valuation

 Valuation Comments/calculations

OFFICE USE ONLY Calculate Inspection Fees on Document Fee

Work Without a Valid Permit Fee

Home of My Own

 FEES  FEE DESCRIPTIO QUANTITY AMOUNT TOTAL

New Residence Deposit 400.00

Plan Check Fees 0.00 Permit Fees 400.00

Total Fees 400.00

 PAYMENTS   DATE TYPE REFERENCE NOTE RECEIPT RECEIVED AMOUNT # FROM

01/24/2024 Credit [number redacted] RES24 51 - Kolten Co 400.00  

Amount Paid 400.00

Balance Due 0.00  PERMIT PROJECT   FILE #: 22-015537 4696 S JACK PINE RD PRESCOTT AZ 86303 104-04-017A: SITE BUILT 2 STORY SINGLE FAMILY RESIDENCE WITH 3 BEDROOMS AND LOFT

       

CONTACT CONTACT TYPE ASSOCIATION CONTACT INFO MAILING ADDRESS

Andrew Myszak Arizona Licensed Applicant Mobile: (812) 890-2063  Registrant Email: [email redacted] Added On: 11/14/2022 Raheel Family Trust Citizen Entry Primary: (602) 881-5713  Rahimullah & Fatima Added On: Email: [email redacted] Raheel 11/14/2022 Randy Instine Citizen Entry Home: (928) 533-1168  Added On: 09/11/2023 Randy Instine Citizen Entry Home: (928) 533-1168  Added On: 09/11/2023

Randy Instine Citizen Entry Home: (928) 533-1168  Added On: 09/11/2023

Arasam Allied Contractor Home: (623) 606-6974 Company Address:  Contractors LLC Added On: Email: 7928 W Pomo st Phoenix Mario Gonzalez 11/23/2022 [email redacted] AZ 85043 Home Address: 7928 W, Pomo st Phoenix AZ 85043 Arasam Allied Contractor Primary: (623) 606-6974 Company Address:  Contractors LLC Added On: Mobile: (623) 606-6974 7928 W POMO ST Mario Gonzalez 11/14/2022 Email: PHOENIX AZ 85043 [email redacted] Home Address: 7928 W POMO ST PHOENIX AZ 85043 CONTACT CONTACT INFO MAILING ADDRESS

CQH Contracting Contractor Primary: (928) 499-0747 Company Address:  LLC Added On: Work: (928) 533-1168 PO BOX 27107 Gary Fortune 09/11/2023 Mobile: (928) 499-0747 PRESCOTT VALLEY AZ Email: 86312 [email redacted] Home Address: 700 WHITE SPAR RD #36 PRESCOTT AZ 86303

CQH, LLC Citizen Entry Primary: (928) 533-1168 Company Address:  CONTRACTING Added On: 700 WHITE SPAR RD 09/11/2023 PRESCOTT AZ 86301 envirotec solutions Arizona Licensed Work: (928) 713-4473 Company Address:  Claude Baker Registrant Mobile: (928) 713-4473 PO Box 10877, Prescott Added On: Home: (928) 445-9611 AZ 86304 03/23/2023 Email: [email redacted] Home Address: PO Box 10877 Prescott AZ 86304-0877 GC CONSULTANTS Citizen Citizen Entry Home: (928) 583-4684 Company Address:  Clyde Neville Added On: Email: 3776 N. Pleasant View Dr. 09/11/2023 [email redacted] Prescott Valley AZ 86314 Myszak + Partners Citizen Entry Primary: (812) 890-2963 Company Address:  Inc. Added On: Email: [email redacted] 6322 W Rose Garden Ln Andrew Mysak 11/14/2022 Glendale AZ 85308 Home Address: 6322 W. Rose Garden Lane Glendale AZ 85308 Complainant Arizona Registrar of Contractors 1700 W Washington St Ste 105 Phoenix, AZ 85007

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C004 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C004 04/21 March 6, 2024

Re: Complaint No. 2023-12569

Dear CQH CONTRACTING LLC:

The Registrar of Contractors opened a formal complaint against your license for Failure to Display your license as required, Aiding and Abetting unlicensed entities, Failure to obtain proper permits and Failure to obtain Worker’s Compensation Insurance.

The Registrar requests that you assist in the agency’s investigation and evaluation of this complaint by submitting a written response to the Registrar within ten (10) days from the date of this letter. Your response should address the allegation(s) raised in the complaint and provide any documentation supporting your response.

Please understand that your written response to the complaint will not be the same as the written answer you would need to file pursuant to A.R.S. §32-1155 if a citation is issued against you.

Thank you for your cooperation.

Sincerely,

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C004 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013e 04/21 March 5, 2024

WARNING LETTER

Re: Complaint No. 2023-12569; License No. ROC 338678

Dear Respondent:

It appears that you may have violated A.R.S. § 32-1124(B). Your jobsite at 1129 N. Turquoise does not have signage that includes your license number preceded by the acronym “ROC.”

written bids submitted by Respondent; broadcast, published, internet, and billboard advertising; and letterheads and any other documents used to correspond with customers or potential customers.

The Registrar does not presently intend to pursue disciplinary action for the alleged violations. However, this warning letter does not preclude the Registrar from electing to pursue action against your license for these violations in the future.

Sincerely,

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013e 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013e 04/21 March 5, 2024

WARNING LETTER

Re: Complaint No. 2023-12569; License No. ROC 338678

Dear Respondent:

It appears that you may have violated A.R.S. § 32-1124(B). Your jobsite at 4696 S. Jack Pine Rd does not have signage that includes your license number preceded by the acronym “ROC.”

written bids submitted by Respondent; broadcast, published, internet, and billboard advertising; and letterheads and any other documents used to correspond with customers or potential customers.

Sincerely,

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C013e 04/21 Respondent: CQH CONTRACTING LLC PO Box 27107 Prescott Valley, AZ 86312

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C014 4/21 March 6, 2024

Re: Complaint No. 2023-12569

Dear CQH CONTRACTING LLC:

During the course of the Registrar’s investigation into complaint 2023-12569, The Registrar determined that you are not in compliance with maintaining Workers Compensation Insurance for your employees.

Failure to maintain workers’ compensation insurance is a violation of A.R.S. §32- 1154(A)(4), which could result in suspension or revocation of your license.

Please provide proof in writing within 30 days of the date of this letter to the Registrar that you are now in compliance with the workers’ compensation laws. Failure to do so may result in a citation being issued against your license.

Your written proof must be submitted to the undersigned at 1700 W Washington St. Suite 105, Phoenix, AZ 85005-2812.

A copy of this notice has been forwarded to the Registrar’s Licensing Department and the Arizona Industrial Commission.

Sincerely,

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C014 4/21 X ROC Review REGISTRAR OF CONTRACTORS C&D STATE OF ARIZONA CIVIL CITATION X CITATION CRIMINAL INVESTIGATION UNIT Case Number FELONY 2023-12569 Date Reported Type of Offense Statute Code County October 11, 2023 Failure to Comply w/ Chapter - Display ROC 32-1154.A.(2)(b), (4), Yavapai License/Failure to obtain permit/Failure to obtain (9), (12)(namely ARS Worker’s Comp/Aid & Abet 32-1124.B) Date of Violation Location of Offense City Various 9760 Towago Prescott Valley C&D Yes No X C&D Served Citation # Property Type Type of Work Job Site Date Ctr Adv Date N/A N/A Com Res X NEW SFR’s 01/08/2024 A&A Yes X No COMPLAINANT X and/or VICTIM Name Address Arizona Registrar of Contractors 1700 W Washington St Ste 105 Phoenix, AZ 85007

Home Phone No. Business Address City (602) 542-1525 SAA SAA

Business Phone No. Amt. of Contract/Bid Amt. Paid Bid Date Permit Req. / Permit No. - 623-680-9585 UNK UNK UNK Various Yes X No Gender Weight Height Hair Eyes Race D.O.B. S.S.NO. Drivers Issued in scars/tattoos/mar n/a n/a n/a n/a n/a n/a n/a n/a License state ks Number n/a n/a n/a SUSPECT and/or RESPONDENT X Name Address CQH CONTRACTING LLC/Gary Fortune PO Box 27107 Prescott Valley, AZ 86312

Home Phone No. Business Name License Number (if any) UNK CQH Contracting LLC ROC 338678

Business Address Business Phone No. 928-499-0474 SAA Gender Weight Height Hair Eyes Race D.O.B. S.S.NO. Drivers License Issued scars/tattoos/mar n/a n/a n/a n/a n/a n/a n/a n/a Number n/a in State ks n/a Additional Participants Name Address Home Phone Bus.Phone No. No. S-2 Clyde Russell Neville, 3776 N. Pleasant View Dr, Prescott Valley, AZ, 86314 928-583-4684

S-3 Randal Laroie Instine, 700 White Spar Rd, #36, Prescott, AZ, 86303 928-533-1168

S-3 David Paul Schlax, Unk unk REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 Jm Dimond #170 County Page 1 of 3 YAVAPAI

SYNOPSIS:

On or about 10/10/2023, I received information from both the Town of Prescott Valley Chief Building Official and the Chief Building Official from Yavapai County. (CBO)

CBO Woody Lewis advised me of a project at 9760 Towago Dr. in Prescott Valley, AZ and that unlicensed entities are running the project and performing unpermitted work. He advised that Clyde Neville is running the project on behalf of CQH Contracting LLC. CQH holds ROC license number 338678.

David Paul Schlax is the Qualifying Party for the license. Gary Fortune is the managing member of the LLC. No other parties are on the license or LLC.

CBO Carrie Holmes (retired) and new CBO Warren Colvin for Yavapai County Building Safety have provided numerous addresses and that the same parties are listed on the permits.

Clyde Neville, Randall Instine and CQH Contracting are listed on the permit.

Clyde Neville holds 2 revoked ROC licenses.

Randall Instine holds 3 revoked ROC licenses.

Randall Instine holds an Office of Manufactured Housing license and that license is suspended and there are pending recovery fund payouts.

DES wage summary records show no reported wages for Neville’s social security number.

DES wage summary records show no reported wages for Instine’s social security number.

DES records also show no record of wages paid to any party for CQH Contracting LLC

A review of the license application for #338678 shows that the applicant indicated that he would comply with worker compensation insurance requirements.

A query of the Industrial Commission web site shows that none of the following parties hold a Worker’s Compensation Insurance policy: David Paul Schlax (QP), Gary Fortune (member), CQH Contracting LLC, Clyde Russell Neville and Randall Laroi Instine.

C034 ODR 08/19 Visit our website: roc.az.gov Page 2 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 Qualifying Party David Paul Schlax appears to be nonexistent regarding the activities of the license.

No less than 4 of the projects lack signage listing the license.

This investigation substantiates that the respondent has committed the following violations:

32-1154. Grounds for suspension or revocation of license; continuing jurisdiction; civil penalty

A. The holder of a license or any person named on a license pursuant to this chapter may not commit any of the following acts or omissions:

2. Departure from or disregard of:

(b) A building code of this state or any political subdivision of this state in any material respect that is prejudicial to another.

4. Failure to comply with the statutes or rules governing social security, workers' compensation or unemployment insurance.

9. Attempting to evade this chapter by:

(a) Aiding or abetting a licensed or unlicensed person.

(b) Acting or conspiring with a licensed or unlicensed person.

(d) Acting as agent, partner, associate or otherwise of a licensed or unlicensed person.

And

12. Failure in any material respect to comply with this chapter:

(namely: 32-1124. License issuance; required posting and placement; license suspension

C034 ODR 08/19 Visit our website: roc.az.gov Page 3 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 B. Licenses issued under this chapter and any renewals shall be signed by the registrar or the registrar's designated representative and by the licensee. The license is nontransferable, and satisfactory evidence of possession shall be exhibited by the licensee on demand. The license number appearing on any licenses held by the licensee must be preceded by the acronym "ROC" and shall be posted or placed as follows:

1. In a conspicuous place on premises where any work is being performed.

2. On all written bids and estimates submitted by the licensee.

3. On all published advertising, letterheads and other documents used by the licensee to correspond with the licensee's customers or potential customers in the conduct of business regulated by this chapter.

4. On all broadcast, internet or billboard advertising, unless the broadcast, internet or billboard advertising includes a website's uniform resource locator that directly links to a website that prominently displays the licensee's name and license number.)

NARRATIVE:

On or about 10/10/23, I was notified by Woody Lewis, CBO of the Town of Prescott Valley, about a project at 9760 Towago Dr, Prescott Valley, AZ, 86314.

This project is a single family home new build. The home is not close to complete at the time of this writing.

CQH Contracting LLC is the contractor of record for this project.

Lewis relayed that the home has had significant issues during the construction and the current largest issue is that a retaining wall installed at the right of way is larger than allowed by the town and does not have engineering as it would be retaining a significant amount of soil.

Lewis relayed that the retaining wall requires a separate permit and Neville/CQH installed the wall. The wall was improper and taller than allowed. A stop work order on the wall was issued pending the obtaining of the proper permit and engineering.

C034 ODR 08/19 Visit our website: roc.az.gov Page 4 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 On 11/30/23, I drove by the project and I took 4 pictures with my state issued Google Pixel 6pro cellphone camera and I have uploaded the pictures to the complaint document file.

There was no signage at the property reflecting the contractor’s license number. On 01/08/24, I sent the respondent the ROC warning letter for failure to display the license.

Mr. Lewis informed me by phone, that Clyde Neville was running the project and is failing to construct the home in accordance to plans and is creating costly errors for the owner.

The unpermitted retaining wall at the front has been recently removed.

One of Mr. Lewis’ inspectors provided 2 emails with the permit information for this address.

One email included photos of the truss ticket and ticket on a package of 2X6’s. The tags said “GC Consultants” or “Clyde”.

Clyde Neville is known to me as an unlicensed entity. GC consultants is known to me to be Clyde Neville as I have seen it on plans.

Lewis indicated that Neville is scheduling and participating in inspections.

The respondent, Gary Fortune provided a note to the town declaring Neville as his representative on the project.

Randy Instine is listed as the email contact on this permit.

Now retired CBO for Yavapai County, Carrie Holmes, included me communications with Neville regarding a home at 833 Cochise in Dewey, Az, 86327.

CQG Contracting LLC is the contractor of record for the address.

On 11/30/23, drove by 833 Cochise and noted that no signage displaying the respondent’s license number was present.

C034 ODR 08/19 Visit our website: roc.az.gov Page 5 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 Per CBO Holmes, Neville has been requesting and participating in the county inspection process.

New CBO Warren Colvin, Yavapai County, has provided me several new addresses.

A permit has been issued for 4696 Jack Pine, Prescott, AZ 86303. This project is a cabin in a remote location on Spruce Mountain.

CQH Contracting LLC is the contractor of record. Clyde Neville and Randy Instine are also listed on the permit

No license number is displayed at this location.

An additional location provided by CBO Colvin is 1129 N. Turquoise for a new single family home.

At the time of this writing, it is just a prepared lot with a little shed and construction has not started.

CQH Contracting LLC is the contractor of record and the applicant is Clyde Neville.

Randy Instine is not listed on this permit.

No license number is displayed at this location.

Both CBO Holmes/Colvin and Lewis have relayed that these parties, namely Neville, cause the departments to use significant resources due to the alleged inability to follow municipal requirements, codes and common construction methods resulting in costly on site errors. It has been reported that Neville repeatedly argues with staff at Yavapai County if he doesn’t agree with a requirement.

Additionally, besides utilizing the ROC’s resources due to a failure to abide by statute and rules, the licensee and “employees” have caused the Office of Manufactured Housing to expend resources with their investigations and proceedings.

I also received ROC complaint number 2024-00106 filed against CQH Contracting LLC for poor work and a failure to complete.

C034 ODR 08/19 Visit our website: roc.az.gov Page 6 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 On 01/19/24, I conducted a jobsite inspection and present was the complaint Tom Carroll and the respondent managing member Gary Fortune as well as Randy Instine.

A directive will be issued in that matter. Signage was present at the time of inspection.

I had correspondence with the homeowner reference Clyde Neville and the complainant has been led to believe that Clyde Neville works for CQH Contracting LLC. That correspondence is uploaded to the complaint document file.

CQH Contracting LLC is listed as the contractor of record for the patio covers at the manufactured home and the detached garage.

Neville is listed at the applicant and Instine is listed as a contact for the permit.

A query of the ROC data base shows that Clyde Russell Neville held the previous licenses:

#091790 and that license was revoked in 1995 #091797 and this license was revoked in 1997

Clyde Russell Neville was convicted of Contracting w/o a license in August of 2022.

In his plea agreement, he was specifically advised of the consequences of unlicensed contracting.

Randall Laroi Instine formerly held the listed 3 ROC licenses:

#182413 and this license was revoked 11/23/04 #183459 this license was revoked 08/12/04 #184764, this license was revoked 11/23/04

Per Jeff Jacobs, Chief of Investigations for the Arizona Office of Manufactured Housing, Instine holds an installer license for manufactured homes and that license is currently suspended and recovery fund payouts have been expended.

I have requested the details of the license and will upload to the complaint document file upon receipt.

C034 ODR 08/19 Visit our website: roc.az.gov Page 7 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 CQH Contracting LLC, #338678 has a qualifying party by the name of David Paul Schlax.

The license applicant was Gary Fortune and he is the sole member of the LLC.

Schlax does not appear to be an employee.

I contacted both CBO’s Warren Colvin and Woody Lewis and their teams report that they have had no contact with Schlax and have no idea who he is.

The notes in this license file indicate that it appears the Randy Instine may have been initially considered to be a part of the license but the previous revocations appear to have played a role in him not being accepted on the license.

Gary Fortune was made aware of the revocation issues with Instine and therefore had to know of Instine’s unlicensed status.

Fortune’s license application indicates that he will comply with Worker’s compensation insurance requirements.

In my email thread with the respondent, he indicates that Neville does as builts, drawings, handles permitting and inspections and reports back to CQH.

Neville is not a registrant with the Bureau of Technical Registration.

The respondent also states that Randy Instine works for CQH.

I conducted a query of the Industrial Commission worker’s comp search engine and found that CQH, Schlax, Fortune, Neville or Instine appear to not hold a Worker’s Comp policy.

By claiming that Instine is an employee, the respondent would then be required to have Worker’s Compensation Insurance.

Additionally, the Towago permit indicates on the list of contractor’s page, that CQH will be performing some substantial tasks.

Having prior knowledge of and meeting Neville previously, he likely is not performing these labor intensive tasks.

C034 ODR 08/19 Visit our website: roc.az.gov Page 8 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 Additionally, if the respondent is going to claim Instine as an employee, it is not likely that Instine can perform these tasks on his own. There are four known current projects going on at the same time. Even if Instine could perform all these tasks solo, he would be spread far too thin to accomplish this work. These tasks include concrete, stucco and drywall. These tasks typically require a crew and are not done solo.

I requested a DES Wage Summary check for the labor year 2023 and discovered the following:

• There is no record for CQH Contracting LLC indicating that there are no employees, including Instine and Neville. • There are no reported wages for Clyde Neville’s social security number • There are no reported wages for Randy Instine’s social security number

CQH/Gary Fortune has provided a W-4 for Instine, however it is incomplete and I am unsure if it has been filed with the department of revenue or the Internal Revenue Service. It is for tax year 2024. Fortune’s response to my request for a 2023 W-4 was “Nothing for 23 I didn't know we needed it”

My prior knowledge of these 3 individuals comes from notifications by CBO Carrie Holmes as the 3 were installing manufactured homes.

Due to a lack jurisdiction, we could not step in most cases and deferred to the Office of Manufactured Housing.

The trio appears to have transitioned to ground up construction of single family homes. The trio does appear to continue with manufactured homes.

David Paul Schlax previously held license number 317796, Custom Quality Home Corp. Schlax was absent regarding the activities of this license as well.

Gary Fortune and Randy Instine were officers with the corporation.

The license was voluntarily cancelled on 06/24/22.

The timing of this may be related to a citizen inquiry (folder notes) regarding Randy Instine and a failure to disclose a felony and revoked licenses.

The CQH Contracting license was issued on 06/09/22.

C034 ODR 08/19 Visit our website: roc.az.gov Page 9 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569 I handled several complaints against Custom Quality Home Corp and have knowledge of not only Instine performing work under that license, Clyde Neville was also involved.

Those complaints fell under the jurisdiction of the Office of Manufactured Housing.

Investigator Dave Thomas has opened an unlicensed case, 2024-02658 against Clyde Neville. A Cease and Desist order with a $2500 fine has been issued.

Subsequent cases will be pending against both Neville and Instine.

SUMMARY:

My investigation regarding this respondent substantiates that the licensee, CQH Contracting LLC/David Paul Schlax and Gary Fortune have regularly been Aiding and Abetting unlicensed entities Clyde Russell Neville and Randall LaRoi Instine on no less than 4 projects that require a license.

DES records support that the respondent doesn’t have employees that they report wages for and both Neville and Instine don’t earn wages that are reported to DES.

Both Neville and Instine have multiple revoked licenses and would have the knowledge that unlicensed contracting is criminal.

Neville has a 2022 conviction for contracting without a license.

The respondent is not in compliance with Worker’s Compensation Insurance requirements.

The respondent regularly does not post signage on jobsites at required.

The respondent did not obtain the proper permitting for the retaining wall on Towago until a stop work order was issued. The incorrect wall had to be removed.

It also appears that the qualifying party to this license does not take part in and may not have knowledge of the day to day operations of the license. (ARS 32-1127)

C034 ODR 08/19 Visit our website: roc.az.gov Page 10 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569

DISPOSITION:

This report is submitted to the ROC Legal department for review and potential discipline.

C034 ODR 08/19 Visit our website: roc.az.gov Page 11 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569

C034 ODR 08/19 Visit our website: roc.az.gov Page 12 of 13 REGISTRAR OF CONTRACTORS CONTINUATION SHEET AND CHECKLIST Investigator: Jim Dimond Case No: 2023-12569

Date March 1, 2024

Attachments Check one Yes No

1. Copy of Original Complaint 2. Additional correspondence from complainant 3. Contract, if available 4. Business cards, ads, etc. 5. Checks (front and back) 6. Building Permits 7. Photos of jobsite 8. Photo lineup 9. Affidavit (when required) 10. Cease and Desist 11. Citation 12. County Attorney’s Office complaint request card 13. Court receipt 14. Other: Supporting documents

C034 ODR 08/19 Visit our website: roc.az.gov Page 13 of 13 4/3/24, 3:53 PM State of Arizona Mail - 2024-12569

James Dimond <[email redacted]>

2024-12569 James Dimond <[email redacted]> Mon, Mar 11, 2024 at 4:58 PM To: Dave Schlax <[email redacted]>, Custom Quality Homes <[email redacted]> Bcc: Dave Thomas <[email redacted]>, Steve Philpott <[email redacted]>, Daniel Otero <[email redacted]>, Brandon Smith <[email redacted]>

Good Afternoon,

Attached is ROC correspondence regarding your methods of operation. Please carefully review the information.

Mr. Neville and Mr. Instine are unlicensed entities and you are Aiding and Abetting them in unlicensed contracting.

If you are going to use Mr. Neville and Mr. Instine, they must be bona fide employees or be properly licensed sub- contractors.

In most cases, they cannot be 1099 independent contractors. They cannot claim to be consultants as defined in statute.

Additionally, by claiming that Mr. Instine is an employee, you then need to obtain Worker's Compensation insurance.

At the Towago house in Prescott Valley, unpermitted work was performed regarding the retaining wall down by the street. A permit was applied for and changes are required that are so significant that the wall has been torn down.

Having visited 4 or your job sites, there is no signage as required.

Please review the attached correspondence and respond as appropriate.

Additionally, your address of record appears to be incorrect as mail directed to you is being returned.

Sincerely,

Jim Dimond #170, Investigator 1700 W. Washington St., Suite 105/Yavapai County Phoenix, Arizona, 85007 Agency Phone: (602)542-1525 Office: (928)637-1463 Cell: (623)680-9585 Fax: (602)542-3919 Email: [email redacted] Hours: Mon. – Fri 0800-1700 The ROC is now on social media! Make sure to follow us on https://mail.google.com/mail/u/0/?ik=6fd2afdf83&view=pt&search=all&permmsgid=msg-a:r-[number redacted]&simpl=msg-a:r-[number redacted]… 1/3 4/3/24, 3:53 PM State of Arizona Mail - 2024-12569

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20240301-Aid and Abet- Randy Instine-2023-12569.pdf 105K 20240301-Aid And Abet- Clyde Neville-2023-12569.pdf 105K 20240305-Worker's Comp notice to R-2023-12569.pdf 87K 20240305-Complaint Allegation Letter-2023-12569.pdf 66K

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https://mail.google.com/mail/u/0/?ik=6fd2afdf83&view=pt&search=all&permmsgid=msg-a:r-[number redacted]&simpl=msg-a:r-[number redacted]… 3/3 BEFORE THE DEPARTMENT OF HOUSING

IN AND FOR THE STATE OF ARIZONA

Patrick Allen, ) ) CASE NO. REC 2022/019 Complainant, ) ) DOCKET NO. 23F-REC2022019-ADH vs. ) ) RANDY INSTINE LLC, ) FINAL ORDER LICENSE NO. 8418, CLASS D-12, ) ) RE: CONSUMER RECOVERY FUND ) Respondent, ) ) ARIZONA DEPARTMENT OF HOUSING ) ) Intervener. ) _________________________________________ )

Pursuant to A.R.S. § 41-1092.08, the Director of the Department of Housing (“Department”)

adopts the Administrative Law Judge Decision (“ALJ Decision”) in its entirety, a copy of which is attached

hereto.

The effective date of this Order is when service is complete. Service is complete upon

personal service or five (5) days after the mailing date indicated below.

Pursuant to A.R.S. § 41-1092.08, the Administrative Law Decision issued by the

Administrative Law Judge is binding on the parties unless a rehearing is granted pursuant to A.R.S. § 41-

4038, which provides that a person aggrieved by a decision of the Administrative Law Judge may apply for

a rehearing by filing with the Director a petition in writing pursuant to A.R.S. § 41-1092.09.

A rehearing may be granted for any of the following reasons materially affecting the moving

party's rights: 1. Irregularity in the proceedings before the director, or any order or abuse of discretion

which deprived the moving party of a fair hearing; 2. Misconduct by the director, the director's employees or

the administrative law judge; 3. Accident or surprise that could not have been prevented by ordinary

prudence; 4. Newly discovered material evidence that could not with reasonable diligence have been

discovered and produced at the original hearing; 5. Excessive or insufficient penalties; 6. Error in the admission or rejection of evidence or other errors of law occurring at the hearing or 7. That the decision is

not justified by the evidence or is contrary to law. See A.R.S. § 41-4038(D).

A motion for rehearing shall be filed within thirty (30) days following the service of this Final

Order. Any motion for rehearing shall be sent to the Department of Housing at 1110 W Washington, Suite

280, Phoenix, Arizona 85007.

This order, which adopts the Administrative Law Judge Decision, is an administrative

decision that is subject to judicial review as prescribed by A.R.S. § 41-1092.08(H).

DATED this 16th day of June, 2023.

ARIZONA DEPARTMENT OF HOUSING

Joan Serviss, Director The foregoing emailed this 26th day of June 2023. via email to:

Patrick Allen [email redacted] The foregoing emailed this _26th____ day of June 2023. via email to: Randy Instine Randy Instine LLC [email redacted] Copy electronically transmitted to: Office of Administrative Hearings 1740 W. Adams St, Lower Level Phoenix, AZ 85007

By: Jeff Jacobs, Investigator

IN THE OFFICE OF ADMINISTRATIVE HEARINGS

Patrick Allen, No. 23F-REC2022019-ADH

Complainant ADMINISTRATIVE LAW JUDGE DECISION vs.

Randy Instine LLC, LICENSE NO. 8418, CLASS D-12,

Respondent.

HEARING: May 22, 2023 APPEARANCES: Complainant Patrick Allen appeared on his own behalf. Respondent failed to appear. ADMINISTRATIVE LAW JUDGE: Adam D. Stone _____________________________________________________________________ 1. Complainants filed claims with the Department’s Consumer Recovery Fund (“the Fund”) pursuant to A.R.S. § 41-4043(A). The Department verified the amounts of the claims pursuant to A.R.S. § 41-4043(B).1 The Department referred the claims to OAH for an evidentiary hearing pursuant to A.R.S. § 41-4043(C). 2. On or about April 19, 2023, the Department issued a Notice of Hearing Re: Consumer Recovery Fund, setting a hearing on May 22, 2023, at 9:00 a.m. The Notice of Hearing alleged that Complainant was seeking an award of $47,500.00 from the Fund. 3. Although the start of the duly noticed hearing was delayed fifteen minutes to allow Respondent additional time, Respondent did not appear, personally or through an attorney, and did not contact OAH to request that the start of the hearing be further delayed. Consequently, Respondent did not present any evidence to challenge the amounts that the Fund should reimburse the Complainant.

See Exhibit B to the Notice of Hearing. HEARING EVIDENCE 4. Complainant testified that he entered into a contract in September 2020 to have Respondent install a Champion Mobile Home and to add an exterior wooden patio deck with a wood cover. 5. Complainant testified Respondent and his subcontractor had assured Complainant that all materials were purchased, however this was not the case. Further, as this construction was during the COVID-19 pandemic, there was a shortage of lumber leading to a significant price increase. 6. Complainant testified that the parties then agreed to modify the contract such that a stem wall would be built and a concrete patio would be installed with an aluminum awning. 7. Complainant testified that while this was started, the stem wall was now failing. Further, there were also other items which were failing such as the septic cleanout.2 8. Complainant testified that he received an e-mail from Respondent in October 2021, that he was terminating the contract. 9. Based upon this, Complainant then filed a Complaint on or about November 23, 2021.3 The Department of Housing issued its report on April 20, 2022, and verified that the concrete patio was not finished, the patio cover was not finished, and the patio retaining wall was cracking.4 10. Complainant then submitted three bids to the Department. One was for $32,050, one was for $99,750.00 and one was for $98,560.00.5 Complainant testified that based upon his discussion with the Department’s investigator, Jeff Jacobs, he decided to seek $47,500.00 from the Fund. 11. Finally, Complainant stated his home still had problems as the belly band was now pulling away do to the stem wall sinking causing the house to become un-level.

See Exhibit A attached to the Notice of Hearing packet. 3 See id. See Exhibit B attached to the Notice of Hearing packet. 5 See Complainant’s Exhibit 1. 2 CONCLUSIONS OF LAW 1. The Department has subject-matter jurisdiction in this matter pursuant to A.R.S. §§ 41-4041, 41-4042, and 41-4043. 2. The Notice of Hearing that the Department mailed to Respondent at his e- mail address of record, was reasonable and Respondent is deemed to have received notice of the hearing.6 3. Complainants bear the burden to establish the amounts of the payouts that they are entitled to recover from the Fund by a preponderance of the evidence.7 “A preponderance of the evidence is such proof as convinces the trier of fact that the contention is more probably true than not.”8 A preponderance of the evidence is “[t]he greater weight of the evidence, not necessarily established by the greater number of witnesses testifying to a fact but by evidence that has the most convincing force; superior evidentiary weight that, though not sufficient to free the mind wholly from all reasonable doubt, is still sufficient to incline a fair and impartial mind to one side of the issue rather than the other.”9 4. A.R.S. § 41-4043 provides in relevant part as follows: A. If any consumer who is buying or selling the consumer's home uses the services of a licensed dealer of manufactured homes, mobile homes or factory-built buildings designed for use as residential buildings and is damaged as a result of an act or omission by a licensed dealer of manufactured homes, mobile homes or factory-built buildings designed for use as residential buildings that constitutes a violation of section 41- 4030, or rules adopted pursuant to that section, and the sale is subject to section 41-4030, subsection C, that consumer may file a claim with the department for payment from the consumer recovery fund. The claim shall be verified by the department. ....

See A.R.S. §§ 41-1092.04; 41-1092.05(D). 7 See A.R.S. § 41-1092.07(G)(2); A.A.C. R2-19-119; see also Vazanno v. Superior Court, 74 Ariz. 369, 372, 249 P.2d 837 (1952). 8 MORRIS K. UDALL, ARIZONA LAW OF EVIDENCE § 5 (1960). BLACK’S LAW DICTIONARY at page 1220 (8th ed. 1999).

3 C. On verification of the claim for payment, the director shall provide for a hearing pursuant to chapter 6, article 10 of this title. D. The director shall pay from the consumer recovery fund whatever sum the administrative law judge finds payable on the claim. A decision granting a claim shall include an order suspending the license of the licensee on whose account the claim was filed. The license shall remain suspended until the licensee has repaid in full, plus interest at the rate of ten percent per year, the amount paid from the consumer recovery fund on the licensee's account. .... G. The consumer recovery fund has a claim against the licensee on whose account a claim was granted or any other person who caused or contributed to a claim paid by the consumer recovery fund for the amount paid plus costs, necessary expenses and reasonable attorney fees. H. The director is subrogated to the claim of the consumer recovery fund against the bond and other assets of the licensee. The director shall deposit any amount recovered into the consumer recovery fund.

5. The Complainant accepted the Department’s calculation and was willing to

accept the verified amount of the payout from the Fund that the Department proposed.

Therefore, a preponderance of the evidence supports payouts from the Fund to the Complainants in the amount of $47,500.00.

ORDER Based upon the foregoing, IT IS ORDERED that on the effective date of the final Order in this matter, the Department shall pay the Complainant the amount of $47,500.00 from the Consumer Recovery Fund: IT IS FURTHER ORDERED that Respondent is hereby notified that the Department’s Consumer Recovery Fund also has a claim against the Respondent for the

4 Department’s costs, necessary expenses, and reasonable attorney’s fees incurred as a result of this matter.

In the event of certification of the Administrative Law Judge Decision by the Director of the Office of Administrative Hearings, the effective date of the Order will be forty (40) days from the date of that certification. Done this day, June 7, 2023.

/s/ Adam D. Stone Administrative Law Judge

Transmitted by either mail, e-mail, or facsimile to:

Joan Serviss, Director Arizona Department of Housing

Randy Instine 3401 N. Valley View Drive Prescott Valley, AZ 86314 [email redacted]

Patrick Allen 1065 N. Cool Water Lane Dewey, AZ 86327 [email redacted] By: OAH Staff

5 BEFORE THE DEPARTMENT OF HOUSING

IN AND FOR THE STATE OF ARIZONA

OFFICE OF ADMINISTRATION, ) ) Complainant, ) CASE NO. 2022-003 ) vs. ) ) ORDER OF SUSPENSION RANDY INSTINE LLC. ) LICENSE NO. 8418, CLASS D-12,

) Respondent. ) )

TO THE ABOVE-NAMED RESPONDENT:

Pursuant to the provisions of Arizona Revised Statutes, (“A.R.S.”), Title 41, Chapter 37,

Articles 3 and 4, Complainant alleges the following:

FACTUAL ALLEGATIONS

1. Randy Instine LLC (“Respondent”) holds dealer license number 8418, Class D-12, issued

by the Department of Fire, Building and Life Safety, that is now the Department of Housing

(“Department”).

2. On or about January 13, 2022, the Department issued a Citation and Complaint by email.

Respondent failed to respond as required in the Citation and Complaint.

CONCLUSIONS OF LAW

Respondent’s failure to respond to the Citation and Complaint shall be deemed an

admission by the Respondent of the factual allegations, and the Department may suspend or

revoke such license without a hearing, pursuant to A.R.S. § 41-4031.

Pursuant to A.R.S. § 41-4039 (1) and (6), Respondent’s license may be suspended, revoked,

subjected to an administrative penalty, or be placed on probation.

///

/// ORDER

THEREFORE, the Department issues the following Order:

License number 8418, Class D-12, shall be suspended, within 30 days of the effective date

of this Order, and shall remain suspended until Respondent submits the required documents.

Should Respondent resolve the above matter prior to the effective date of this Order, the

Order of Suspension may be dismissed.

This Order is a final administrative action and is effective upon service. Service is

complete on personal service or within 5 days of being served via email.

Respondent may request a formal hearing on the disciplinary action taken in this Order by

submitting a written request to the Department via First Class Mail at 1110 West Washington,

Suite 280, Phoenix, Arizona 85007, or email [email redacted] , addressed to the Arizona

Department of Housing, within ten (10) days of the effective date of this order. Formal hearings

are held before an Administrative Law Judge at the Office of Administrative Hearings.

EFFECTIVE this 16th day of February, 2022.

Tara Brunetti, Assistant Deputy Director Arizona Department of Housing

The foregoing emailed this ___16th______ day of February, 2022, to: Randy Instine LLC. 3401 N Valley View Dr. Prescott Valley, AZ 86314 Respondent/Qualifying Party Copy sent this ___16th____ day of February, 2022, email to: Nancy Carmen-Engle 3925 W. Cindy Lane Chino Valley, AZ 86323 Complainant

By: ______________ Jeff Jacobs, Investigator REGISTRAR OF CONTRACTORS STATE OF ARIZONA Supplemental Report INVESTIGATION UNIT Case Number 2023-12569 Investigator Jim Dimond #170 Narrative:

On 03/11/2024, I received 6 documents via from Jeff Jacobs, Division Administrator/Investigator at the Arizona Department of Housing- Manufactured Housing and Building Division.

The documents are reference discipline and recovery fund payouts against respondent Randall Instine.

The result was the suspension of Instine’s D-12 license due to two recovery fund payouts totaling $108110 ($60,610 and $47,500).

This information was requested as background information as Instine appears to have been initially a part of the CQH Contracting license.

The information is also supporting information regarding the behavior of the licensee in engaging questionable ‘contractors’ on projects and that the behavior has caused 2 state agencies along with at least 2 building departments to expend resources to halt their illegal activity.

The documents have been uploaded to the complaint document file

C034a 08/19 Investigations’ Department Citation Recommendation

Complaint No: 2023-12569 Investigator: Jim Dimond

Cite Per 32-1154.A: 1. A.R.S. § 32-1154(A)(3) - R4-9-108(b) Violation of any rule adopted by the Registrar; Namely A.A.C. R4-9-108(b): A contractor shall perform all work in accordance with any applicable building codes and professional industry standards. For work to be performed in accordance with professional industry standards, a contractor shall use such skills, prudence, and diligence in performing and completing tasks undertaken that the completed work meets the standards of a similarly licensed contractor possessing ordinary skill and capacity. 2. A.R.S. § 32-1154(A)(4) Failure to comply with the statutes or rules governing social security, workers's compensation or unemployment insurance. 3. A.R.S. § 32-1154(A)(9)(a) Attempting to evade this chapter by: (a) Aiding or abetting a licensed or unlicensed person. 4. A.R.S. § 32-1154(A)(9)(b) Attempting to evade this chapter by: (b) Acting or conspiring with a licensed or unlicensed person. 5. A.R.S. § 32-1154(A)(9)(c) Attempting to evade this chapter by: (c) Allowing one?s license to be used by a licensed or unlicensed person. 6. A.R.S. § 32-1154(A)(9)(d) Attempting to evade this chapter by: (d) Acting as agent, partner, associate or otherwise of a licensed or unlicensed person. 7. A.R.S. § 32-1154(A)(12) - A.R.S. § 32-1124(B) Failure in any material respect to comply with this chapter; Namely A.R.S. § 32-1124(B).

If violation description was “3.Other” what specific rule was violated? If violation description was “13.Other” what is the specific violation of this chapter?

Is the ROC Investigator’s testimony required at the hearing? Choose an item. 1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C019 8/19 Consider citing additional license(s): Choose an item. Was respondent present at jobsite inspection?: Choose an item. Possibly combine this case for hearing w/Case No(s): Choose an item. Other Notes: Date: April 5, 2024

1700 W. Washington Street, Suite 105 · Phoenix AZ 85007-2812 602.542.1525 · Toll Free 877.692.9762 · roc.az.gov C019 8/19 INSURED MAILER PAGE

Reference: 0022WCV037080500

CQH CONTRACTING LLC 5121 N MISSION LN PRESCOTT VALLEY, AZ 86314

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P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * 678-309-4077 * www.bldrs.com DE: Nuevo Asegurado de Builders Insurance Group PARA: Builders Insurance Group ASUNTO: Cobertura del Seguro de Compensación para el Trabajador

Bienvenido a Builders Insurance Group, su nuevo socio y proveedor de seguro de Compensación para el Trabajador. Sírvase revisar el paquete de información acerca de la cobertura que estamos adjuntando a esta carta, asegúrese de que dicha información llegue a la persona responsable de administrar la cobertura de su seguro.

Builders Insurance Group cuenta con productos de seguros para compensación del trabajador y de responsabilidad civil general diseñados específícamente para satisfacer las necesidades de la comunidad de constructores de viviendas. Somos la empresa de seguros para la propiedad comercial y contra siniestros más grande en el estado de Georgia y proveedor líder en el mercado de compensación al trabajador en el sureste del país. Entre las empresas miembros de Builders Insurance Group están Builders Insurance (una Empresa de Captive Company), American Builders Insurance Company, Georgia Builders Insurance Company, National Builders Insurance Company, Building Industry Insurance Association Inc., y United Builders Insurance Company.

Este paquete para asegurados nuevos contiene:

• La información sobre su póliza • La prima estimada junto con su factura • Aviso de Comisión de Fraudes • Instrucciones para solicitar una indemnización • Información sobre el programa de Administración de Costos • Formularios de Primer Reporte de Lesión y Declaración de Salario • Aviso de Privacidad de las empresas miembros de Builders Insurance Group • Aviso de Publicación Oficial (si es necesario)

Nuestro compromiso siempre será ofrecerle oportunidades de ahorrar recursos, a través de tarifas competitivas, planes de pago sin intereses y excelentes servicios de indemnización y adminstración de seguridad. Tenemos disponibles un Crédito para Empresas Libres de Drogas y/o un Plan de Deducibles para los asegurados que llenen los requisitos.

Nuestro Departamento de Control de Pérdidas y Servicios de Seguridad tiene la capacidad de proporcionarle información, recursos y materiales valiosos para procurar que sus empleados trabajen con más seguridad y que su empresa opere con eficiencia. Tenemos a su disposición Consultores en Control de Pérdidas con quiences podrá discutir las medidas de prevención de pérdidas y técnicas de administración de indemnizaciones que le ayudarán a disminuir la presentación de solicitudes de beneficios junto con los costos asociados. Estos servicios se ofrecen sin costo alguno.

Le agradecemos la oportunidad de ofrecerle productos y servicios para satisfacer sus necesidades de aseguramiento y esperamos que esta sociedad que hoy comenzamos dure por un largo tiempo. Póngase en contacto con nuestros agentes independientes o con Builders Insurance Group al 678-309-4000 o al 1-800-883-9305 si tiene cualquier pregunta acerca de esta información.

Gracias por permitirnos atenderle. of

BIG NB PHN S 05 15

P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * 678-309-4077 * www.bldrs.com American Builders Insurance Company Election To Accept Or Reject Insurance Deductible For Arizona Workers Compensation Indemnity and Medical Benefits Effective 01/01/2024

Each insurer transacting or offering to transact workers compensation insurance in Arizona may offer deductibles to employers. Deductibles are available for medical and indemnity benefits, and shall apply separately to each claim for bodily injury by accident or disease.

Hazard Groups Deductible Amount A B C D E F G $500 6.0% 4.5% 3.2% 2.9% 2.1% 1.6% 1.2% $1,000 10.0% 7.7% 5.5% 5.0% 3.7% 2.7% 2.2% $1,500 12.9% 10.0% 7.3% 6.6% 5.0% 3.6% 3.0% $2,000 15.2% 12.0% 8.8% 7.9% 6.1% 4.5% 3.7% $2,500 17.1% 13.5% 10.0% 9.0% 6.9% 5.2% 4.3% $5,000 23.1% 18.9% 14.4% 13.0% 10.2% 7.8% 6.7% $10,000 29.8% 25.1% 19.9% 17.9% 14.4% 11.3% 9.8% $15,000 33.9% 29.0% 23.5% 21.3% 17.3% 14.0% 12.1% $20,000 37.2% 32.3% 26.5% 24.2% 19.8% 16.2% 14.1% $25,000 39.8% 34.9% 29.0% 26.7% 21.9% 18.1% 15.9% $30,000 41.9% 37.2% 31.2% 28.9% 23.7% 19.9% 17.5% $35,000 43.9% 39.1% 33.1% 30.7% 25.3% 21.3% 18.8% $40,000 45.5% 40.7% 34.8% 32.4% 26.9% 22.8% 20.2% $50,000 48.2% 43.6% 37.7% 35.2% 29.4% 25.3% 22.5%

Please note that deductibles are based on Hazard group codes related to specific classifications. You are not required to choose a deductible program. However, if you choose a program, it is to be understood that your insurance company will administer and pay all claims, and that you will reimburse the insurance company for payments made within the amount of the deductible selected. The payment or nonpayment of deductible amounts by the insured employer to the insurer shall be treated under the policy insuring the liability for workers compensation in the same manner as payment or nonpayment of premiums.

Please indicate whether or not you want a deductible by initialing the appropriate choice below.

X _____Yes, 500 I want a deductible of $___________ applied to indemnity and medical benefits under the Arizona Workers Compensation Law. I understand that the company shall pay the deductible amount and be reimbursed by the employer shown below.

_____ No, I do not want the deductible described in the Notice.

I have the option of modifying the above deductible program choice at the time of renewal of my workers compensation insurance policy with the insurance company named below.

(Signature) (Title)

American Builders Insurance Company WCV 0370805 00 (Carrier) (Policy Number) (Date)

NOTE TO INSURED: Please indicate your choice of a deductible or non-deductible program and return the signed form to your agent. Thank You. of

WC AZ ABIC DED OPT POLICY NUMBER: WCV 0370805 00

INSURED: CQH CONTRACTING LLC

American Builders Insurance Company A Stock Company P.O. Box 723099 Atlanta, GA 31139-0099

WORKERS COMPENSATION POLICY

For: CQH CONTRACTING LLC By: PROFESSIONAL INS STRATEGIES 5121 N MISSION LN 3655 W. ANTHAN WAY PRESCOTT VALLEY, AZ 86314 A-109283 PHOENIX, AZ 85086

IN WITNESS WHEREOF, we have caused this policy to be executed and attested, and, if required by State law, this policy shall not be valid unless countersigned by our authorized representative.

President Secretary

For Inquiry purposes, coverage information and complaint assistance, please contact your agent or call:

1-800-883-9305 or 678-309-4000 of

WC 02 00 00 B 03 16 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

INFORMATION PAGE Insurer: (NCCI Carrier Code 25496) Producer: 0002853 American Builders Insurance Company PROFESSIONAL INS STRATEGIES A Stock Company 3655 W. ANTHAN WAY P.O. Box 723099 A-109283 Atlanta, GA 31139-0099 PHOENIX, AZ 85086

1. The Insured and Mailing Address: Carrier Policy #: WCV 0370805 00 CQH CONTRACTING LLC Carrier Prior Policy # 5121 N MISSION LN PRESCOTT VALLEY, AZ 86314 Type of Business: LIMITED LIAB CO(LLC) Fein: [number redacted] Risk ID:

Other workplaces not shown above: See the Schedule of Workplaces for this policy.

2. The Policy Period is from 12:01 a.m. on 04/06/2024 to 12:01 a.m. on 04/06/2025 at the Insured's mailing address.

3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Arizona

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: Alabama Colorado Florida Georgia Indiana Maryland Michigan Mississippi North Carolina Oklahoma Pennsylvania South Carolina Tennessee Virginia

D. This policy includes these endorsements and schedules: See endorsement schedule. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code No. Premium Basis Rate Per Estimated Total Estimated $100 of Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS

Total Estimated Annual Premium $1,807 of

Minimum Premium $658 Expense Constant $160

COUNTERSIGNED BY

WC 00 00 01 A 04 15

Copyright 1994 National Council on Compensation Insurance, Inc. WORKERS COMP & EMPLOYERS LIABILITY American Builders Insurance Company A Stock Company Policy Number: WCV 0370805 00 P.O. Box 723099 Named Insured: CQH CONTRACTING LLC Atlanta, GA 31139 Agent: PROFESSIONAL INS STRATEGIES 0002853

SCHEDULE OF OPERATIONS

Premium Basis Rate Per Estimated Code Classification Description Total Est. Annual $100 of Annual No. Remuneration Remuneration Premium

Arizona Rating Period 04/06/2024 through 04/06/2025 Site 00001 5606 CONTRACTOR-EXECUTIVE SUPERVISOR/SUPERINTENDENT 20,000 0.6400 128.00 6217 EXCAVATION & DRIVERS 56,000 2.3600 1,322.00 Site 00001 Total $ 1,450.00 9812 INCREASED LIMITS OF EMPLOYERS LIABILITY 1,450 0.0110 16.00 9664 BENEFIT DEDUCTIBLE CREDIT (SUBJECT TO EMOD) 1,450 -0.0120 -17.00 9848 TO EQUAL MINIMUM PREMIUM (E L) 104.00 9889 SCHEDULED MODIFICATION 1,553 1.0500 78.00 0063 PREMIUM DISCOUNT 1,631 0.00 0900 EXPENSE CONSTANT 160.00 9740 TERRORISM ACT SURCHARGE 76,000 0.0100 8.00 9741 CATASTROPHE OTHER THAN CERTIFIED ACTS OF TERRORISM 76,000 0.0100 8.00 Rating Period Total $ 1,807.00

Total Estimated Premium $ 1,807.00 $ 1,807.00

$ 1,807.00

Issued Date: 04/08/2024 WC 99 06 52 0415 Page 1 of 1 WORKERS COMP & EMPLOYERS LIABILITY American Builders Insurance Company Policy Number: WCV 0370805 00 A Stock Company P.O. Box 723099 Named Insured: CQH CONTRACTING LLC Atlanta, GA 31139 Agent: PROFESSIONAL INS STRATEGIES 0002853

SCHEDULE OF WORKPLACES

Site 1 CQH CONTRACTING LLC 5121 N MISSION LN PRESCOTT VALLEY, AZ 86314

Issued Date: 04/08/2024 WC 99 06 53 0415 Page 1 of 1 WORKERS COMP & EMPLOYERS LIABILITY American Builders Insurance Company Policy Number: WCV 0370805 00 A Stock Company P.O. Box 723099 Named Insured: CQH CONTRACTING LLC Atlanta, GA 31139 Agent: PROFESSIONAL INS STRATEGIES 0002853

NAMED INSURED SCHEDULE

CQH CONTRACTING LLC 5121 N MISSION LN PRESCOTT VALLEY, AZ 86314

FEIN: [number redacted]

Issued Date: 04/08/2024 WC 99 06 51 0415 Page 1 of 1 WORKERS COMP & EMPLOYERS LIABILITY American Builders Insurance Company Policy Number: WCV 0370805 00 A Stock Company P.O. Box 723099 Named Insured: CQH CONTRACTING LLC Atlanta, GA 31139 Agent: PROFESSIONAL INS STRATEGIES 0002853

ENDORSEMENT SCHEDULE

State Form Nbr Ed. Date Description US WC000000C (1/15) WC AND EMPLOYERS LIAB INS POL

US WC000310 (4/84) SOLE PROP, PART, OFFICER ENDT

AZ WC000406A (7/95) PREMIUM DISCOUNT ENDORSEMENT

AZ WC000414A (1/19) NOTIFICATION OF CHANGE IN OWNE

AZ WC000419A (8/22) PREMIUM DUE DATE

AZ WC000421F (8/22) CATASTROPHE PREMIUM ENDT

AZ WC000422C (1/21) TERRORISM RISK INS PROGRAM

AZ WC000424 (1/17) AUDIT NONCOMPLIANCE CHARGE END

AZ WC000425 (5/17) EXP RATING MOD FACTOR REV ENDT

AZ WC020401C (2/10) AZ ALCOHOL & DRUG FREE ENDT

AZ WC020601C (9/21) AZ CANCELLATION, NONRNL ENDT

AZ WC020602A (3/21) AZ BENEFITS DEDUCTIBLE ENDT

AZ WC020603A (12/22) AZ AMENDATORY ENDORSEMENT

Issued Date: 04/08/2024 WC 99 06 50 0415 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

American Builders Insurance Company P.O. Box 723099 (A Stock Company) Atlanta, GA 31139-0099

QUICK REFERENCE

Beginning on Page Beginning INFORMATION PAGE on Page PART TWO - EMPLOYERS GENERAL SECTION..................................... 1 LIABILITY INSURANCE (con't) A. The Policy......................................... 1 H. Recovery From Others.................... 4 B. Who Is Insured................................ 1 I. Actions Against Us.......................... 4 C. Workers Compensation Law 1 D. State................................................. 1 PART THREE - E. Locations.......................................... 1 OTHER STATES INSURANCE...................... 4 A. How This Insurance Applies.............. 4 PART ONE - WORKERS B. Notice............................................... 4 COMPENSATION INSURANCE......................... 1 PART FOUR - YOUR DUTIES A. How This Insurance Applies 1 IF INJURY OCCURS..................................... 4 B. We Will Pay...................................... 1 C. We Will Defend................................ 1 PART FIVE - PREMIUM................................ 5 D. We Will also Pay.............................. 1 A. Our Manuals..................................... 5 E. Other Insurance................................ 1 B. Classifications................................... 5 F. Payments You Must Make................ 2 C. Remuneration.................................... 5 G. Recovery From Others...................... 2 D. Premium Payment............................. 5 H. Statutory Provisions.......................... 2 E. Final Premium................................... 5 F. Record.............................................. 5 PART TWO - EMPLOYERS G. Audit................................................. 5 LIABILITY INSURANCE................................ 2 A. How This Insurance Applies 2 PART SIX - CONDITIONS B. We Will Pay...................................... 2 A. Inspection......................................... 6 C. Exclusions......................................... 3 B. Long Term Policy............................. 6 D. We Will Defend................................ 3 C. Transfer of Your Rights and Duties.... 6 E. We Will Also Pay.............................. 3 D. Cancellation...................................... 6 F. Other Insurance............................... 4 E. Sole Representative.......................... 6 G. Limits of Liability............................... 4 41 of

These Policy Provisions with the Information Page and Endorsements, if any, issued to form a part thereof, complete this policy.

PLEASE READ THIS POLICY CAREFULLY

BIG Q REF 05 15 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C

(Ed. 1-15)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all PART ONE terms of this policy, we agree with you as follows: WORKERS COMPENSATION INSURANCE

GENERAL SECTION A. How This Insurance Applies

A. The Policy This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily This policy includes at its effective date the injury includes resulting death. Information Page and all endorsements and schedules listed there. It is a contract of insurance between you 1. Bodily injury by accident must occur during the (the employer named in Item 1 of the Information policy period. Page) and us (the insurer named on the Information 2. Bodily injury by disease must be caused or Page). The only agreements relating to this insurance aggravated by the conditions of your employment. are stated in this policy. The terms of this policy may The employee’s last day of last exposure to the not be changed or waived except by endorsement conditions causing or aggravating such bodily issued by us to be part of this policy. injury by disease must occur during the policy period.

B. Who is Insured You are insured if you are an employer named in Item B. We Will Pay of the Information Page. If that employer is a We will pay promptly when due the benefits required partnership, and if you are one of its partners, you are of you by the workers compensation law. insured, but only in your capacity as an employer of the partnership’s employees. C. We Will Defend We have the right and duty to defend at our expense C. Workers Compensation Law any claim, proceeding or suit against you for benefits Workers Compensation Law means the workers or payable by this insurance. We have the right to workmen’s compensation law and occupational investigate and settle these claims, proceedings or disease law of each state or territory named in Item suits. 3.A. of the Information Page. It includes any We have no duty to defend a claim, proceeding or suit amendments to that law which are in effect during the that is not covered by this insurance. policy period. It does not include any federal workers or workmen’s compensation law, any federal occupational disease law or the provisions of any law D. We Will Also Pay that provide nonoccupational disability benefits. We will also pay these costs, in addition to other amounts payable under this insurance, as part of any D. State claim, proceeding or suit we defend: State means any state of the United States of 1. reasonable expenses incurred at our request, but America, and the District of Columbia. not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the E. Locations amount payable under this insurance; This policy covers all of your workplaces listed in Items

3. litigation costs taxed against you; or 4 of the Information Page; and it covers all other 4. interest on a judgment as required by law until we of

workplaces in Item 3.A. states unless you have other insurance or are self-insured for such workplaces. offer the amount due under this insurance; and

5. expenses we incur.

E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other

(Ed. 1-15)

insurance or self-insurance. Subject to any limits of workers compensation law that apply to: liability that may apply, all shares will be equal until the a. benefits payable by this insurance; loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will b. special taxes, payments into security or other be equal until the loss is paid. special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the F. Payments You Must Make workers compensation law are changed by this You are responsible for any payments in excess of the statement to conform to that law. benefits regularly provided by the workers Nothing in these paragraphs relieves you of your compensation law including those required because: duties under this policy. 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of PART TWO law; EMPLOYERS LIABILITY INSURANCE 3. you fail to comply with a health or safety law or A. How This Insurance Applies regulation; or This employers liability insurance applies to bodily 4. you discharge, coerce or otherwise discriminate injury by accident or bodily injury by disease. Bodily against any employee in violation of the workers injury includes resulting death. compensation law. 1. The bodily injury must arise out of and in the If we make any payments in excess of the benefits course of the injured employee’s employment by regularly provided by the workers compensation law you. on your behalf, you will reimburse us promptly. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item G. Recovery From Others 3.A. of the Information Page. We have your rights, and the rights of persons entitled 3. Bodily injury by accident must occur during the to the benefits of this insurance, to recover our policy period. payments from anyone liable for the injury. You will do 4. Bodily injury by disease must be caused or everything necessary to protect those rights for us and aggravated by the conditions of your employment. to help us enforce them. The employee’s last day of last exposure to the conditions causing or aggravating such bodily H. Statutory Provisions injury by disease must occur during the policy period. These statements apply where they are required by law. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by 1. As between an injured worker and us, we have accident or by disease must be brought in the notice of the injury when you have notice. United States of America, its territories or 2. Your default or the bankruptcy or insolvency of possessions, or Canada. you or your estate will not relieve us of our duties under this insurance after an injury occurs. B. We Will Pay 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. We will pay all sums that you legally must pay as Those persons may enforce our duties; so may an damages because of bodily injury to your employees, agency authorized by law. Enforcement may be provided the bodily injury is covered by this Employers

against us or against you and us. Liability Insurance. The damages we will pay, where recovery is of

4. Jurisdiction over you is jurisdiction over us for permitted by law, include damages:

purposes of the workers compensation law. We are bound by decisions against you under that 1. For which you are liable to a third party by reason law, subject to the provisions of this policy that are of a claim or suit against you by that third party to not in conflict with that law. recover the damages claimed against 5. This insurance conforms to the parts of the

(Ed. 1-15) such third party as a result of injury to your and 901–944), any other federal workers or employee; workmen’s compensation law or other federal 2. For care and loss of services; and occupational disease law, or any amendments to these laws; 3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; 9. Bodily injury to any person in work subject to the provided that these damages are the direct Federal Employers’ Liability Act (45 U.S.C. consequence of bodily injury that arises out of and Sections 51 et seq.), any other federal laws in the course of the injured employee’s obligating an employer to pay damages to an employment by you; and employee due to bodily injury arising out of or in the course of employment, or any amendments to 4. Because of bodily injury to your employee that those laws; arises out of and in the course of employment, claimed against you in a capacity other than as 10. Bodily injury to a master or member of the crew of employer. any vessel; and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure C. Exclusions under any appli-cable maritime law; This insurance does not cover: 11. Fines or penalties imposed for violation of federal or state law; and 1. Liability assumed under a contract. This exclusion does not apply to a warranty that your work will be 12. Damages payable under the Migrant and done in a workmanlike manner; Seasonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other 2. Punitive or exemplary damages because of bodily federal law awarding damages for violation of injury to an employee employed in violation of law; those laws or regulations issued thereunder, and 3. Bodily injury to an employee while employed in any amendments to those laws. violation of law with your actual knowledge or the actual knowledge of any of your executive officers; D. We Will Defend 4. Any obligation imposed by a workers compensa- tion, occupational disease, unemployment We have the right and duty to defend, at our expense, compensation, or disability benefits law, or any any claim, proceeding or suit against you for damages similar law; payable by this insurance. We have the right to investigate and settle these claims, proceed-ings and 5. Bodily injury intentionally caused or aggravated by suits. you; We have no duty to defend a claim, proceeding or suit 6. Bodily injury occurring outside the United States of that is not covered by this insurance. We have no America, its territories or possessions, and duty to defend or continue defending after we have Canada. This exclusion does not apply to bodily paid our applicable limit of liability under this injury to a citizen or resident of the United States insurance. of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, E. We Will Also Pay demotion, evaluation, reassignment, discipline, We will also pay these costs, in addition to other defamation, harassment, humiliation, amounts payable under this insurance, as part of any discrimination against or termination of any claim, proceeding, or suit we defend: employee, or any personnel practices, policies, acts or omissions; 1. Reasonable expenses incurred at our request, but not loss of earnings; Bodily injury to any person in work subject to the 2. Premiums for bonds to release attachments and

Longshore and Harbor Workers’ Compensation Act (33 U.S.C. Sections 901 et seq.), the for appeal bonds in bond amounts up to the limit of

Non-appropriated Fund Instrumentalities Act (5 of our liability under this insurance;

U.S.C. Sections 8171 et seq.), the Outer 3. Litigation costs taxed against you; Continental Shelf Lands Act (43 U.S.C. Sections 4. Interest on a judgment as required by law until we 1331 et seq.), the Defense Base Act (42 U.S.C. offer the amount due under this insurance; and Sections 1651–1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. 5. Expenses we incur.

(Ed. 1-15) F. Other Insurance 2. The amount you owe has been determined with We will not pay more than our share of damages and our consent or by actual trial and final judgment. costs covered by this insurance and other insurance or This insurance does not give anyone the right to add self-insurance. Subject to any limits of liability that us as a defendant in an action against you to apply, all shares will be equal until the loss is paid. If determine your liability. The bankruptcy or insolvency any insurance or self-insurance is exhausted, the of you or your estate will not relieve us of our shares of all remaining insurance and self-insurance obligations under this Part. will be equal until the loss is paid.

PART THREE G. Limits of Liability OTHER STATES INSURANCE Our liability to pay for damages is limited. Our limits of A. How This Insurance Applies liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Infor- 1. Bodily Injury by Accident. The limit shown for mation Page. “bodily injury by accident—each accident” is the most we will pay for all damages covered by this 2. If you begin work in any one of those states after insurance because of bodily injury to one or more the effective date of this policy and are not insured employees in any one accident. or are not self-insured for such work, all provisions of the policy will apply as though that state were A disease is not bodily injury by accident unless it listed in Item 3.A. of the Information Page. results directly from bodily injury by accident. 3. We will reimburse you for the benefits required by 2. Bodily Injury by Disease. The limit shown for the workers compensation law of that state if we “bodily injury by disease—policy limit” is the most are not permitted to pay the benefits directly to we will pay for all damages covered by this persons entitled to them. insurance and arising out of bodily injury by disease, regardless of the number of employees 4. If you have work on the effective date of this policy who sustain bodily injury by disease. The limit in any state not listed in Item 3.A. of the shown for “bodily injury by disease—each Information Page, coverage will not be afforded for employee” is the most we will pay for all damages that state unless we are notified within thirty days. because of bodily injury by disease to any one employee. B. Notice Bodily injury by disease does not include disease that results directly from a bodily injury by Tell us at once if you begin work in any state listed in accident. Item 3.C. of the Information Page.

3. We will not pay any claims for damages after we have paid the applicable limit of our liability under PART FOUR this insurance. YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by H. Recovery From Others this policy. Your other duties are listed here. We have your rights to recover our payment from 1. Provide for immediate medical and other services anyone liable for an injury covered by this insurance. required by the workers compensation law. You will do everything necessary to protect those 2. Give us or our agent the names and addresses of rights for us and to help us enforce them. the injured persons and of witnesses, and other information we may need.

I. Actions Against Us 3. Promptly give us all notices, demands and legal There will be no right of action against us under this of

insurance unless:

1. You have complied with all the terms of this policy; and

(Ed. 1-15) papers related to the injury, claim, proceeding or suit. D. Premium Payments You will pay all premium when due. You will pay the 4. Cooperate with us and assist us, as we may premium even if part or all of a workers compensation request, in the investigation, settlement or law is not valid. defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. E. Final Premium 6. Do not voluntarily make payments, assume The premium shown on the Information Page, obligations or incur expenses, except at your own schedules, and endorsements is an estimate. The cost. final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully PART FIVE—PREMIUM apply to the business and work covered by this policy. A. Our Manuals If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we All premium for this policy will be determined by our will refund the balance to you. The final premium will manuals of rules, rates, rating plans and not be less than the highest minimum premium for the classifications. We may change our manuals and classifications covered by this policy. apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: B. Classifications 1. If we cancel, final premium will be calculated pro Item 4 of the Information Page shows the rate and rata based on the time this policy was in force. premium basis for certain business or work Final premium will not be less than the pro rata classifications. These classifications were assigned share of the minimum premium. based on an estimate of the exposures you would 2. If you cancel, final premium will be more than pro have during the policy period. If your actual exposures rata; it will be based on the time this policy was in are not properly described by those classifications, we force, and increased by our short-rate cancelation will assign proper classifications, rates and premium table and procedure. Final premium will not be basis by endorsement to this policy. less than the minimum premium.

C. Remuneration F. Records Premium for each work classification is determined by You will keep records of information needed to multiplying a rate times a premium basis. compute premium. You will provide us with copies of Remuneration is the most common premium basis. those records when we ask for them. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: G. Audit 1. all your officers and employees engaged in work You will let us examine and audit all your records that covered by this policy; and relate to this policy. These records include ledgers, 2. all other persons engaged in work that could make journals, registers, vouchers, contracts, tax reports, us liable under Part One (Workers Compensation payroll and disbursement records, and programs for Insurance) of this policy. If you do not have storing and retrieving data. We may conduct the payroll records for these persons, the contract audits during regular business hours during the policy price for their services and materials may be used period and within three years after the policy period ends. Information developed by audit will be used to

as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of determine final premium. Insurance rate service of

these persons lawfully secured their workers organizations have the same rights we have under this provision.

compensation obligations.

(Ed. 1-15) PART SIX—CONDITIONS If you die and we receive notice within thirty days after A. Inspection your death, we will cover your legal representative as insured. We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability D. Cancelation of the workplaces and the premiums to be charged. 1. You may cancel this policy. You must mail or We may give you reports on the conditions we find. deliver advance written notice to us stating when We may also recommend changes. While they may the cancelation is to take effect. help reduce losses, we do not undertake to perform the duty of any person to provide for the health or 2. We may cancel this policy. We must mail or safety of your employees or the public. We do not deliver to you not less than ten days advance warrant that your workplaces are safe or healthful or written notice stating when the cancelation is to that they comply with laws, regulations, codes or take effect. Mailing that notice to you at your standards. Insurance rate service organizations have mailing address shown in Item 1 of the Information the same rights we have under this provision. Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. B. Long Term Policy 4. Any of these provisions that conflict with a law that If the policy period is longer than one year and controls the cancelation of the insurance in this sixteen days, all provisions of this policy will apply as policy is changed by this statement to comply with though a new policy were issued on each annual the law. anniversary that this policy is in force.

E. Sole Representative C. Transfer of Your Rights and Duties The insured first named in Item 1 of the Information Your rights or duties under this policy may not be Page will act on behalf of all insureds to change this transferred without our written consent. policy, receive return premium, and give or receive notice of cancelation.

(Ed. 4-84)

SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT

An election was made by or on behalf of each person described in the Schedule to be subject to the workers compensation law of the state named in the Schedule. The premium basis for the policy includes the remuneration of such persons.

Schedule

Persons State AZ

Sole Proprietor:

Partners

Officers:

Others: GARY FORTUNE

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

WC 00 03 10 (Ed. 4-84)

(Ed. 7-95)

PREMIUM DISCOUNT ENDORSEMENT

The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount.

Schedule

1. State Estimated Premium

AZ First Next Next $10,000 $190,000 $1,550,000 Balance 0.0% 5.1% 6.5% 7.5%

2. Average percentage discount: 0.000 %

3. Other policies:

4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number:

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

WC 00 04 06 A (Ed. 7-95)

(Ed. 1-19)

90-DAY REPORTING REQUIREMENT—NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT

You must report any change in ownership to us in writing within 90 days of the date of the change. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity, and other changes provided for in the applicable experience rating plan. Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Failure to report any change in ownership, regardless of whether the change is reported within 90 days of such change, may result in revision of the experience rating modification factor used to determine your premium. This reporting requirement applies regardless of whether an experience rating modification is currently applicable to this policy.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

WC 00 04 14 A (Ed. 1-19)

(Ed. 08-2022)

Part Five—Premium Amendatory Endorsement

This endorsement amends Part Five—Premium of the policy as follows: Part Five—Premium, Section A. (Our Manuals) is replaced by the following provision:

A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates and loss costs (as applicable), rating plans, forms, endorsements, and classifications, and such manuals are expressly incorporated by reference into, and apply to, this policy and any renewals (our manuals). As used in this policy and any renewals, our manuals means manuals that have been: 1. Developed in any format and filed by the state-designated workers compensation rating or advisory organization on our behalf with the appropriate state insurance regulatory authority; or 2. Developed in any format and filed by the respective state rating bureau on our behalf with the appropriate state insurance regulatory authority; or 3. Developed in any format and filed by us with the appropriate state insurance regulatory authority; and 4. For each or any of the three scenarios above, the manuals also must be approved for use by the appropriate state insurance regulatory authority, or as otherwise authorized by law as applicable. We may change our manuals and apply the changes to this policy and any renewals if such manual changes are approved for use by the appropriate state insurance regulatory authority, or as otherwise authorized by law as applicable.

Part Five—Premium, Section D. (Premium Payments) is replaced by the following provision:

D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the due date specified in the billing for the policy.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

WC 00 04 19 A (Ed. 08-2022)

(Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas)

Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement

This endorsement is notification that we are charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). Coverage for such losses is subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement attached to this policy. For purposes of this endorsement, Catastrophe (Other Than Certified Acts of Terrorism) is defined as: A single event or peril resulting in a group of claims with aggregate workers compensation losses in excess of $50 million. This $50 million threshold applies per occurrence, across all states for which claims arise from a single event or peril. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below.

Schedule State Rate Premium AZ 0.0100 $8

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

WC 00 04 21 F (Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas) of 1 © Copyright 2021 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C

(Ed. 01-2021)

Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement

This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. “Insured Loss” means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year.

(Ed. 01-2021)

Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice

1. Insured Losses would be partially reimbursed by the United State Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in item 4 of the Information Page or in the Schedule below.

Schedule

State Rate Premium

AZ 0.010000 $8

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

(Ed. 1-17)

AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT

Part Five—Premium, Section G. (Audit) of the Workers Compensation and Employers Liability Insurance Policy is revised by adding the following: If you do not allow us to examine and audit all of your records that relate to this policy, and/or do not provide audit information as requested, we may apply an Audit Noncompliance Charge. The method for determining the Audit Noncompliance Charge by state, where applicable, is shown in the Schedule below. If you allow us to examine and audit all of your records after we have applied an Audit Noncompliance Charge, we will revise your premium in accordance with our manuals and Part 5—Premium, E. (Final Premium) of this policy. Failure to cooperate with this policy provision may result in the cancellation of your insurance coverage, as specified under the policy. Note: For coverage under state-approved workers compensation assigned risk plans, failure to cooperate with this policy provision may affect your eligibility for coverage.

Schedule

State(s) Basis of Audit Noncompliance Maximum Audit Noncompliance Charge Charge Multiplier

AZ Estimated Annual 2.00 Premium

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

WC 00 04 24 (Ed. 1-17)

(Ed. 5-17)

EXPERIENCE RATING MODIFICATION FACTOR REVISION ENDORSEMENT

This endorsement is added to Part Five—Premium of the policy.

The premium for the policy is adjusted by an experience rating modification factor. The factor shown on the Information Page may be revised and applied to the policy in accordance with our manuals and endorsements. We will issue an endorsement to show the revised factor, if different from the factor shown, when it is calculated.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

WC 00 04 25 (Ed. 5-17)

(Ed. 02-2010)

Arizona Alcohol- and Drug-Free Workplace Premium Credit Endorsement

This endorsement applies only to the insurance provided by the policy because Arizona is shown in Item 3.A. of the Policy Information Page. This endorsement provides notice that premium for your policy may be affected by the Arizona Alcohol- and Drug-Free Workplace Premium Credit Program. You may qualify for a 5% premium credit if you have established and maintain a qualifying alcohol- and drug-free workplace program in accordance with Title 23, Chapter 2, Article 14 of Arizona Statutes. We will determine your eligibility for this premium credit after total premium has been paid for the policy period and may be revised at the time your final premium audit is processed. The determination that you have a qualifying program must be made each year that you receive the premium credit. To implement a premium credit program, the following guidelines must be established: 1. Insurers offering the premium credit program may apply a 5% premium credit to qualifying employers. 2. To receive the premium credit, you must: a. Provide a written statement to the insurer prior to or within 30 days after the beginning of the policy effective date each year, certifying that the business has implemented a program meeting the requirements of Title 23, Chapter 2, Article 14. b. At any time during the term of the policy, provide additional information to the insurer, as required, to confirm that a qualifying program has been established and is being maintained. c. Comply with the alcohol and drug testing policy requirements in accordance with Title 23, Chapter 2, Article 14. d. Conduct alcohol and drug testing of prospective employees. e. Conduct alcohol and drug testing of an employee after the employee has been injured. f. Allow us to have access to the alcohol and drug testing results under d. and e. above. 3. The determination that you have established and maintain a qualifying program must be made during each policy term that you receive the premium credit. 4. Your certification and any other information relied upon by the insurer in granting the premium credit must be kept in the insurer's underwriting files and made available to the Department of Insurance upon request. 5. The premium credit may be applied after total premium has been paid for the policy period and may be revised at final audit to the employer's policy. The credit is applicable as a supplement to deviated rates and is applied in a multiplicative manner, after the application of the experience modification, and before the application of the premium discount and expense constant. 6. You must reimburse the premium credit if it is determined that you were not in compliance with the provisions of the program. 7. Minimum premium policies are eligible for this premium credit. 8. Residual market employers are eligible to apply for this premium credit.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

(Ed. 09-2021) Arizona Cancellation and Nonrenewal Endorsement

This endorsement applies because Arizona is shown in Item 3.A. of the Information Page. Part Six—Conditions, Section D. (Cancellation) of the policy is replaced by the following: D. Cancellation and Nonrenewal 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. If you cancel or fail to renew this policy, we must promptly notify the Industrial Commission of Arizona. 3. We may cancel this policy if you fail to pay premium when due, or when one or both of the parties to a professional employer agreement terminate the agreement. If we cancel or nonrenew this policy, we must provide to you and the Industrial Commission of Arizona at least 30 days’ notice of the cancellation or nonrenewal. Notice to you may be sent via mail or delivered by electronic means as follows: Mailing that notice to you at your last-known mailing address on file with us will be sufficient proof of notice. Delivery to an email address at which you have consented to receive notices or documents. Posting on a portal, secure website, electronic network or site accessible via the Internet or a mobile application, computer, mobile device, tablet, or other electronic device, together with a separate notice that includes a description of the document or notice that was posted and that was provided by email to the email address at which you consented to receive notice, or by any other delivery method to which you consented. If you consented to have the notice emailed in accordance with Arizona law, emailing that notice to you at your last-known email address as provided by you to us will be sufficient proof of notice. If the email notice is: (1) rejected for delivery; (2) returned to us; or (3) we become aware that the email address provided by you is no longer valid, then we will also mail that notice to you by US Postal Service certified mail, certificate of mailing, or first-class mail using intelligent mail barcode, or another similar tracking method used or approved by the US Postal Service. If we nonrenew this policy and fail to give you notice of nonrenewal, coverage will not extend beyond the policy period. 4. The policy period will end on the date and time stated in the cancellation or nonrenewal notice. 5. Any of these provisions that conflict with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with the law.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

(Ed. 03-2021)

Arizona Benefits Deductible Endorsement

This endorsement applies because Arizona is shown in Item 3.A. of the Information Page. 1. Part One—(Workers Compensation Insurance) applies only to benefits in excess of the deductible amount shown in the Schedule. 2. The selected deductible applies on a per-claim basis and to a claim's total indemnity and medical loss, with the option by the employer of including or excluding any loss adjustment expenses . 3. We will pay the deductible amount for you, but you must reimburse us within 30 days after we send you notice that payment of the deductible amounts is due. If you fail to fully reimburse us, we may cancel the policy as provided in Part Six—(Conditions), Section D. (Cancellation), of the policy. We may keep the amount of unearned premium that will reimburse us for the payments we made. These rights are in addition to other rights we have to be reimbursed. 4. This endorsement must specify whether loss adjustment expenses will be treated as advancements within the deductible to be reimbursed by you.

Yes, loss adjustment expenses are considered as advancements within the deductible amount to be reimbursed by the employer. No, loss adjustment expenses are not considered as advancements within the deductible amount to be reimbursed by the employer.

You may choose only one deductible amount

Schedule Deductible Amount $500

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No.

Insured: CQH CONTRACTING LLC Premium: $1,807.00 of

Insurance Company: American Builders Insurance Company Countersigned by:

WC 02 06 02 A (Ed. 03-2021) of 1

(Ed. 12-2022)

Arizona Amendatory Endorsement This endorsement applies because Arizona is shown in Item 3.A. of the Information Page. Item 2. of the Information Page is replaced by the following:

2. The policy period is from 04/06/2024 to 04/06/2025 12:01 a.m. in the time zone of the insured's mailing address. For endorsements issued during the policy period, the effective date is in the time zone of the insured’s mailing address.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. of

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective: Policy No. WCV 0370805 00 Endorsement No. Insured: CQH CONTRACTING LLC Premium: $1,807.00

Insurance Company: American Builders Insurance Company Countersigned by:

HELP STOP WORKERS' COMPENSATION RIP OFFS!

Workers' Compensation fraud hurts every employee/employer covered by Builders Insurance Group*. When someone fakes or exaggerates a job related injury or illness to collect benefits, that is Workers' Compensation fraud. When an employer under-reports payroll, this is also Workers' Compensation fraud.

This multi-billion dollar problem represents a significant cost each year to every American family in the form of higher insurance premiums, taxes and costs of other goods and services. Higher Workers' Compensation insurance rates leave the employer with less money to provide employees with raises, paid vacations and other employee benefits.

You can help put a stop to this abuse. If you believe there is Workers' Compensation fraud, call the toll-free FRAUD HOTLINE AT 1-800-883-9305 Ext. 4154. Your call is strictly confidential. After we receive your call, Builders Insurance Group will conduct a thorough claims/premium investigation. If sufficient evidence of fraud is uncovered, we may turn the case over to the local District Attorney's office for further investigation and possible prosecution.

Call the Hotline and Put a Stop to Fraudulent Workers' Compensation Claims! 1-800-883-9305 Ext. 4154

* Member companies of Builders Insurance (An Association Captive Company), American Builders Insurance Company, Georgia Builders Insurance Company, National Builders Insurance Company, Building Industry Insurance Association Inc., and United Builders Insurance Company. BIG FRAUD PHN E 05 15

P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * 678-309-4077 * www.bldrs.com AVISO DE COMISIÓN DE FRAUDES

iAYÚDENOS A EVITAR LOS FRAUDES DE SEGUROS!

El fraude de Seguros de Compensación para el Trabajador es un duro golpe para todos los empleados y empleadores cubiertos por Builders Insurance Group. Se considera que una persona comete un fraude con el Segura de Compensacó n para el Trabajador cada vez que se finge o exagera una enfermedad o lesión relacionada con el trabajo para cobrar una indemnización, o cuando un empleador proporciona información falsa relacionada con la nómina.

Este problema multimillionario representa un costo significativo todos las años para cada familia en este país, debido al incremento que representa en las primas de seguros, impuestos y costos de otros bienes y servicios. Las primas de seguro en aumento se traducen en que el empleador no tendrá los recursos para ofrecer a sus trabajadores aumentos, vacaciones pagadas y otras prestaciones.

Está en sus manos detener estos abusos. Llame si costo a la LíNEA DIRECTA PARA REPORTE DE FRAUDES al 1-800-883-9305 Ext. 4154 si cree que se está cometiendo este delito. Su llamada será estrictamente confidencial. Después de recibir dicha llamada llevaremos a cabo una completa investigación de indemnizaciones/ primas. Si se encuentran suficientes evidencias de la comisión de un fraude es posible que turnemos el caso a las autoridades locales para continuar los procedimientos de investigación y persecución del delito.

¡Llame a Nuestra Línea Directra, Ayúdenos a Detener a Quienes Cometen estos Abusos! 1-800-883-9305 Ext. 4154

* Entre las empresas miembros de Builders Insurance (una Empresa de Captive Company), American Builders Insurance Company, Georgia Builders Insurance Company, National Builders Insurance Company, Building Industry Insurance Association Inc., y United Builders Insurance Company. BIG FRAUD PHN S 05 15

P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * 678-309-4077 * www.bldrs.com Important Payment Information

For your convenience, we offer on-line bill pay at www.bldrs.com (click on "Pay Bill Online") for an instant payment option. We can also accept a fax of your check at 678-309-4077. Both methods will result in immediate posting of your payment.

Late Notice A Late Notice will be issued after the due date if payment has not been received.

Cancellation Notice A cancellation Notice will be issued after the due date if payment has not been received. Note: A $30 additional fee is charged to each policy that is cancelled for non-payment and subsequently reinstated.

Payments Received After Cancellation or Lapse Any payment receivd after your policy lapses or is cancelled will be credited against any amounts owed to us, but not applied to the policy. This does not obligate us to reinstate the policy or extend coverage. Any refund due will be issued to the insured afer the policy audit has been processed.

Mailing Instructions Please remit Workers' Compensation premiums to:

Builders Insurance Group P.O. Box 723099 Atlanta, GA 31139-0099

If you have any questions about your billing, please contact your independent agent or the Premium Accounting Department of Builders Insurance Group at 678-309-4000, option 5 or 800-883-9305, option 5.

ABIC/NBIC/BIIA

BIG IPI PHN E 05 15

P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * Fax 678-309-4077 * www.bldrs.com Información Importante acera de sus Pagos

Para su comodidad le ofrecemos la opción de pagar su factura en línea en www.bldrs.com , haciendo clic en el vinculo “Pague su Factura en Linea” (Pay Bill Online). Este método nos permitirá confirmar su pago de inmediato. Aviso de Deuda en Mora

Si no se recibe el pago posterior a la fecha de vencimiento se emitirá un “Aviso de Deuda en Mora”.

Aviso de Cancelacion Si no se recibi el pago posterior a la fecha de vencimiento se emitirá un “Aviso de Cancelacion”.

Nota: Se cobrara una cuota adicional de $30 a todas las cuentas canceladas por falta de pago que sean reactivadas posteriormente.

Los Pagos Recibidos Despues de la Cancelacion o Lapso Cualquier pago recibido después de que su poliza fue cancelada será acreditada a cualquier cantidad que usted nos deba ; pero no será aplicada a la poliza. Esto no nos obliga a reinstalar la poliza o extender la cobertura. Cualquier devolución debida será otorgada a la aseguradora después de que la auditoria de la poliza sea procesada.

Instrucciones para Enviar por Correo Sirvase enviar los pagos de sus primas de Seguro al: Builders Insurance Group P.O. Box 723099 Atlanta, GA 31139-0099

Póngase en contacto con su agente de seguros independiente o con el Departamento de Administración de Primas de Builders Insurance Group al 678-309-4000, opción 5 o 1-800-883-9305, opción 5 si tiene alguna pregunta acerca de su factura.

ABIC/NBIC/BIIA

BIG IPI PHN S 05 15

P.O. Box 723099 * Atlanta, GA 31139-0099 * 678-309-4000 * 800-883-9305 * Fax 678-309-4077 * www.bldrs.com The following information is provided in accordance with applicable state and federal laws and regulations. No action on your part is necessary.

PRIVACY NOTICE OF THE BUILDERS INSURANCE GROUP COMPANIES

Builders Insurance Group, Inc., Association Services, Inc., American Builders Insurance Company, National Builders Insurance Company, Specialty Builders Insurance Company, Builders Insurance (An Association Captive Company), Building Industry Insurance Association Inc., Georgia Builders Insurance Company, and United Builders Insurance Company referred to as “Builders Insurance Group”

This privacy policy does not apply to your relationship with other financial service providers, such as your insurance agent or broker, which are not part of the Builders Insurance Group. Their privacy policies govern how they collect, use and disclose personal information that you allow them to access.

What categories of information about you do we collect?

We may collect the following categories of nonpublic personal information about you from the following sources:

Information about you that you provide to us on applications for our products or services or other forms, such as your address, telephone number, income, assets, insurance policies, social security numbers, payroll information, and accounts with others; Information about your transactions and experiences with us, our affiliates and nonaffiliated third parties, such as your insurance coverages, claims, loss or other transaction history, premium payments; and Information we obtain about you from consumer reporting agencies.

What categories of information about you do we disclose?

We may disclose all of the personal information that we collect, as described above, to our affiliates and nonaffiliated third parties as required or permitted by law. In some cases, this means that we can disclose information about you to certain third parties without your authorization.

How do we protect the confidentiality and security of your information?

We restrict access to your nonpublic personal information in our records to our employees who need to know that information to provide our products or services to you, and for other reasons required or permitted by law. We maintain physical, electronic and procedural safeguards to guard the confidentiality and security of your nonpublic personal information in our records. Our employees who violate our privacy policy are subject to disciplinary action.

Builders Insurance Group follows these privacy practices even when a customer relationship no longer exists.

You have the right to obtain access to certain types of information about you in our records and to request

correction of such information if you feel it is inaccurate. We would be pleased to tell you about our policies and of

procedures regarding the privacy of your nonpublic personal information. Please contact us in writing at

Builders Insurance Group, P.O. Box 723099, Atlanta, GA 31139-0099 regarding our privacy notice.

BIG PRVN 03 20 OTHER STATES COVERAGE NOTICE

POLICYHOLDERS

The Workers Compensation Coverage Provided By The Workers Compensation And Employer's Liability Policy Applies Only To Benefits Required By The Workers Compensation Act For The States Listed In Item 3A.

It Is Possible For An Employee To Be Injured On The Job Under Circumstances That Would Allow The Workers Compensation Benefits Of Another State To Be Payable To The Employee.

However, This Policy Does Not Provide "OTHER STATES" Coverage If The State Is Not Listed. Therefore, The Employer May Be Solely Responsible For Paying Those Benefits And Other Related Costs Imposed By The Jurisdiction.

Contacting Your Agent And Obtaining A Workers' Compensation Policy Can Close This Potential Coverage Gap.

BIG OSC PHN 05 15 How to File a Claim

Policyholder Responsibility:

As soon as you are notified of the loss, immediately contact Builders Insurance Group using one of the following methods: > Report via Internet: www.bldrs.com and click on "File a Claim."

> Call 1-800-883-9305, listen to prompts, and dial 2 for 24/7 loss reporting (please advise the intake specialist if you have any concerns regarding the validity of the claim).

> E-mail: [email redacted]

> Fax: 678-631-3409

Builders Insurance Group’s Responsibility: > Builders Insurance Group will prepare the state required First Report of Injury on WC losses and forward a copy to you for your records.

> Builders Insurance Group will assign a claims adjuster to handle the loss and contact you for additional details.

> If you receive additional information regarding the loss such as: medical bills, medical reports, legal forms, court orders, etc, please send them to:

Builders Insurance Group Claims Department P.O. Box 723099 Atlanta, GA 31139-0099

BIGCL PHN E 05 15 Cómo Presentar Una Reclamación

Responsabilidad del Titular:

Tan pronto como se le notifique de la pérdida, comuníquese inmediatamente con Builders Insurance Group Insurance utilizando uno de los siguientes métodos: > Informe a través de Internet: www.bldrs.com y haga clic en "Presentar Una Reclamación.

> Llame 1-800-883-9305, escuche las indicaciones, y marque 2 para asistencia 24 / 7 para reportar su pérdida (por favor avise al especialista en el consumo si tiene alguna duda sobre la validez de la reclamación).

> E-mail: [email redacted]

> Fax: 678-631-3409

Responsabilidad de Builders Insurance Group: > Builders Insurance Group preparará el Primer Informe de Lesión requerido por el estado sobre las pérdidas de Compensación a los Trabajadores y enviará una copia para sus registros.

> Builders Insurance Group le asignará un ajustador de seguros para manejar la pérdida y se comunicará con usted para obtener más detalles.

> Si recibe información adicional acerca de la pérdida, tales como: gastos médicos, informes médicos, formas jurídicas, las órdenes judiciales, etc, por favor envíelas a:

Builders Insurance Group Departamento de Reclamo P.O. Box 723099 Atlanta, GA 31139-0099

BIGCL PHN S 05 15 Workers’ Compensation Temporary Prescription ID Card

Tarjeta de identificación temporal para medicamentos con recetas de compensación de los trabajadores

To the Injured Worker: myMatrixx, an Express Scripts Company On your first visit, please give this notice to any pharmacy listed on the back side to speed processing your approved workers’ compensation prescriptions (based on the ID# (N.o de identificación): guidelines established by your employer). Your SSN is your temporary ID number; present to the pharmacy at the time Questions or need assistance locating a participating retail network pharmacy? Call prescription is filled. You will receive a new ID number shortly. the myMatrixx Patient Care Contact Center at 866-499-1903. El n.° de Seguro Social (SSN) es su número de identificación temporal. Recibirá un nuevo número de identificación a la brevedad. To the Pharmacist: myMatrixx, an Express Scripts company administers this workers’ compensation Date of Injury: prescription program. Please follow the steps below to submit a claim. Fecha de la lesion MM/DD/YYYY Standard claim limitations include Group #: 738A Quantity exceeding 150 pills N.° de grupo Day supply exceeding 7 days Dollar amount exceeding $150 Employee Date of Birth: Form is valid for up to 30 days from DOI Fecha de nacimiento (DOB) del empleado Only specific medications allowed

For assistance, call myMatrixx at 888-786-9640.

Pharmacy Processing Steps Thank you for using a participating retail network pharmacy. Step 1: Enter bin number 003858 Even though there is no direct cost to you, it’s important that we Step 2: Enter processor control WC all do our part to help control the rising cost of healthcare. Step 3: Enter the group number as it appears above Please see other side for a list of participating retail network Step 4: Enter the injured worker’s nine-digit ID number Step 5: Enter the injured worker’s first and last name pharmacies Step 6: Enter the injured worker’s date of injury Gracias por usar una farmacia que participa en la red de Para el trabajador lesionado: venta al por menor. Si bien no tiene que pagar ningún costo En la primera visita, entregue este aviso a cualquiera de las farmacias que se indican al dorso para agilizar el procesamiento de las recetas aprobadas de compensación directo, es importante que todos colaboremos para ayudar a de los trabajadores (según las pautas establecidas por el empleador). controlar el aumento de los costos de atención médica. Consulte el dorso para obtener una lista de las farmacias que ¿Tiene preguntas o necesita ayuda para localizar alguna de las farmacias que participan en la red de venta al por menor? Llame al Centro de contacto para la participan en la red de venta al por menor. atención al paciente de Express Scripts al 866-499-1903.

Para el farmacéutico: Express Scripts administra este programa de medicamentos con recetas de To the Supervisor: Please fill in the information compensación de los trabajadores. Siga los pasos indicados a continuación para presentar una reclamación. requested for the injured worker. Las limitaciones para una reclamación estándarincluyen: La cantidad supera las 150 pastillas Para elsupervisor: Complete la información solicitada Elsuministro diario supera los 7 días para el trabajador lesionado. El monto en dólares supera los $150 Este formulario es válido por hasta 30 días desde la fecha de la lesión (DOI). Solo se permiten medicamentos específicos. Employee Information (Información del empleado) Para asistencia, llame a Express Scripts al 866-499-1903. 41

Pasos de procesamiento de la farmacia of

First (Nombre) M (2.° ) Last (Apellido) Paso 1: Ingrese el número de ubicación 003858 Paso 2: Ingrese el procesador de control WC

Paso 3: Ingrese el número de grupo como aparece arriba Street Address or PO Box (Dirección o casilla de correo) Paso 4: Ingrese el número de identificación de nueve dígitos del trabajador lesionado Paso 5: Ingrese el nombre y el apellido del trabajador lesionado City (Ciudad) State (Estado) ZIP (Código postal) Paso 6: Ingrese la fecha de la lesión del trabajador lesionado

Employer Name (Nombre del empleador)

CRP1806_0245 EME46657 OT48017I Page 1 Workers’ Compensation Temporary Prescription ID Card

Tarjeta de identificación temporal para medicamentos con recetas de compensación de los trabajadores

Participating Retail Network Pharmacies Farmacias que participant en la red de venta al por menor

A&P Drug Emporium Longs Drug Store Save Mart Acme Pharmacy Drug Fair Major Value Schnucks Albertson’s Drug Town Marsh Drugs Scolari’s Albertson’s/Acme Drug World Medic Discount Sedano Albertson’s/Osco Eckerd Medicap Shaw’s Albertson’s/Sav-On Econofoods Medistat Shop ‘N Save Amerisource Bergen EPIC Pharmacy Network Meijer Shopko Anchor Pharmacies FamilyMeds Minyard ShopRite Arrow Farm Fresh NCS HealthCare Snyder Aurora Farmer Jack Neighborcare Stop & Shop Bartell Drugs Food City Network Pharmaceuticals Sun Mart Bigg’s Food Lion Northeast Pharmacy Services Super Fresh Bi-Lo Fred’s Osco Super Rx Bi-Mart Gemmel P & C Food Markets Target BJ’s Wholesale Club Giant Pamida Texas Oncology Srvs Brooks Giant Eagle Park Nicollet The Pharm Brookshire Brothers Giant Foods Pathmark Thrifty White Brookshire Grocery Hannaford Pavilions Times Bruno Harris Teeter Price Chopper Tom Thumb Carrs H-E-B Publix Tops Cash Wise Hi-School Pharmacy Quality Markets Ukrop’s Coborn’s Hy-Vee Raley’s United Drugs Costco Jewel/Osco Randalls United Supermarkets Cub Kash n Karry Rite Aid Vons CVS Keltsch Rosauers Waldbaums D&W Kerr Rx Express Walgreens Dahl’s Kmart RXD Wal-Mart Dierbergs Knight Drugs Safeway Wegmans Discount Drugmart Kroger Sam’s Club Weis Doc’s Drugs LeaderNet (PSAO) Sav-On Winn Dixie Dominicks

CRP1806_0245 EME46657 OT48017I Page 2 TO BE POSTED BY EMPLOYER POLICY NUMBER WCV 0370805 00

NOTICE TO EMPLOYEES RE: ARIZONA WORKERS’ COMPENSATION LAW

All employees are hereby notified that this employer has complied with the provisions of the Arizona Workers’ Compensation Law (Title 23, Chapter 6, Arizona Revised Statutes) as amended, and all the rules and regulations of The Industrial Commission of Arizona made in pursuance thereof, and has secured the payment of compensation to employees by insuring the payment of such compensation with: American Builders Insurance Company

All employees are hereby further notified that in the event they do not specifically reject the provisions of the said compulsory law, they are deemed by the laws of Arizona to have accepted the provisions of said law and to have elected to accept compensation under the terms thereof; and that under the terms thereof employees have the right to reject the same by written notice thereof prior to any injury sustained, and that the blanks and forms for such notice are available to all employees at the office of this employer.

************** PARA SER COLOCADO POR EL PATRON NUMERO DE POLIZA WCV 0370805 00

AVISO A LOS EMPLEADOS RE: LEY DE COMPENSACION PARA LOS TRABAJADORES DE ARIZONA

A todos los empleados se les notifica por este medio que este patron ha cumplido con las provisiones de la Ley de Compensacion para los Trabajadores de Arizona (Titulo 23, Capitulo 6, Estatutos Enmendados de Arizona) tal como han sido enmendados, y con todas las reglas y ordenanzas de La Comision Industrial de Arizona hechas en cumplimiento de esta, y ha asegurado el pago de compensacion a los empleados garantizando el pago de dicha compensacion por medio de: American Builders Insurance Company

Ademas, a todos los empleados se les notifica por este medio que en caso de que especificadamente ellos no rechazen las disposiciones de dicha ley obligatoria, se les considerara bajo las leyes de Arizona de haber aceptado las provisiones de dicha ley y de haber escogido aceptar la compensacion bajo estos terminos; tambien bajo estos terminos los empleados tienen el derecho de rechazar la misma por medio de una notificacion por escrito antes de que sufran alguna lesion, todos los formularios o formas en blanco para tal notificacion por escrito estaran disponibles para todos los empleados en la oficina de este patron.

************** KEEP POSTED IN A CONSPICUOUS PLACE.

COLOQUESE EN LUGAR VISIBLE. Katelyn Rolling <[email redacted]>

ROC Citation and Complaint 2023-12569 - DO NOT REPLY message

Katelyn Rolling <[email redacted]> Mon, Sep 23, 2024 at 2:39 PM To: [email redacted]

Hello,

Attached, please find an electronic courtesy copy of the Citation and Complaint issued in Complaint No. 2023-12569. This document was also sent to your attention via US Mail.

Please do not reply directly to this email. Any reply or response should be addressed to [email redacted].

Katelyn Rolling Legal Assistant II Arizona Registrar of Contractors 1700 W Washington St Ste 105 Phoenix, AZ 85007 (602) 542-1525

20240924 Citation and Complaint MAILED 2023-12569.pdf 16862K Received 10/08/2024 ROC Legal Received 10/08/2024 ROC Legal Received 10/8/24, 11:28 AM State of Arizona Mail - case # 2023-12569 10/08/2024 ROC Legal

Answers - AZROC <[email redacted]>

case # 2023-12569 message

GARY FORTUNE <[email redacted]> Tue, Oct 8, 2024 at 11:05 AM To: "[email redacted]" <[email redacted]>

Virus-free.www.avast.com

ANSWERS.pdf 1578K

https://mail.google.com/mail/b/AEoRXRTgS8tjBFGOSmfKTUD7HCG5fxFXkN_tKyixnM04r5-FFrPU/u/0/?ik=581c53cf5c&view=pt&search=all&permthid… 1/1 Mediation Notice

Mediation Services Mediation services are available to the parties. What is Mediation? Mediation is a method of resolving disputes where the parties can end conflict without the expense and time associated with the full administrative process. Who Participates in During mediation, a mediator will attempt to help the Mediation? parties find an optimal solution to the conflict. Both parties must agree to participate in mediation, and both parties must bring a representative to mediation that has full authority to settle the entire matter. Mediation Is Not Neither the Registrar nor the Office of Administrative Mandatory Hearings will penalize a party for not agreeing to mediation. Where do the Parties The parties will meet at the Office of Administrative Meet for Mediation? Hearings to participate in mediation.

The Office of Administrative Hearings is located at 1400 West Washington, Suite 101, Phoenix, Arizona 85007. When does Mediation can occur after the Registrar issues a citation, but Mediation Occur? before the administrative hearing. Why Should Parties Mediation can be an alternative to the full administrative Consider Mediation? process. Mediation is beneficial because it is (1) time- efficient, (2) cost-effective, (3) confidential, and (4) capable of providing flexible solutions to complex problems. How to Request If the parties wish to mediate this case, they must file a Joint Mediation Request for Mediation with the Office of Administrative Hearings. A Joint Request for Mediation is included with this Mediation Notice. REGISTRAR OF CONTRACTORS OF THE STATE OF ARIZONA _________________________ Case No. _______________ COMPLAINANT,

v. JOINT REQUEST FOR MEDIATION _________________________ RESPONDENT.

REQUEST

The parties jointly request that this matter be referred to mediation in the Office of Administrative Hearings (OAH). ☐ This matter is set for hearing on __________________(date). ☐ This matter is not currently set for hearing. MEDIATION AGREEMENT By requesting this mediation and signing below, the parties understand, represent, and agree: 1. The parties are prepared to commence mediation and will be ready for mediation on _____________________(date); 2. The parties will participate in the mediation process in good faith; 3. This request for mediation is not intended to hinder or delay administrative proceedings; 4. No party will contend that the mediation limits the power of OAH and its administrative law judges to conduct an administrative hearing and issue decisions under A.R.S. §§ 41-1092 – 1092.12; 5. The parties will be courteous and respectful throughout the mediation process to all participants; 6. The mediation is completely voluntary and the principal purpose is to allow the parties a full and fair opportunity to discuss settlement; of 3 REGISTRAR OF CONTRACTORS 1700 W. Washington St. Suite 105 – PHOENIX, AZ 85007-2812 Telephone (602)542-1525 1-877-692-9762 7. The mediator may conduct joint and separate meetings with the parties and may suggest resolutions to the parties’ dispute, but the mediator has no authority to impose a settlement upon the parties; 8. The mediation process is confidential. Communications made, material created for or used during, and acts occurring during mediation are confidential and may not be discovered or admitted into evidence in any proceeding except as provided by A.R.S. § 12-2238; 9. The mediator is not subject to service of process or a subpoena to produce evidence or to testify regarding any evidence or occurrence relating to the mediation except as provided in A.R.S. § 12-2238(C); 10. Neither the mediator, nor the Registrar of Contractors, nor the Office of Administrative Hearings is subject to civil liability for any act or omission in connection with any mediation service or activity except for acts involving

intentional misconduct or reckless disregard of a substantial risk of injury to the rights of others; 11. Throughout the mediation process, each party must have a representative present who will have full settlement authority to settle all claims at issue in the administrative

proceeding. 12. The mediation process will terminate when: a. The parties reach settlement; b. The mediator determines that further efforts at mediation are no longer likely

to achieve a settlement; or c. One of the parties withdraws from mediation. _____________________________________ _______________________ Complainant (or representative) Date

_____________________________________ _______________________ Respondent (or representative) Date

of 3 REGISTRAR OF CONTRACTORS 1700 W. Washington St. Suite 105 – PHOENIX, AZ 85007-2812 Telephone (602)542-1525 1-877-692-9762 PREHEARING DISCLOSURE STATEMENT INSTRUCTIONS ***DO NOT SUBMIT THESE INSTRUCTIONS WITH THE PREHEARING DISCLOSURE FORM***

ADMINISTRATIVE RULES A copy of the Arizona Administrative Code’s Rules for the Registrar of Contractors can be located on the Registrar’s Website.

PREHEARING DISCLOSURE REQUIREMENT Under A.A.C. R4-9-118(A), before a hearing, the parties must prepare a disclosure statement. The disclosure statement must contain: • A list of all the witnesses the party will call to testify, including the witnesses’ contact information and a brief description of the subject matter of the witnesses’ expected testimony; and • A list of all the exhibits that the party will use at the hearing.

FILE PREHEARING DISCLOSURE STATEMENTS • The Prehearing Disclosure Statements and Exhibits may be submitted to the Arizona Office of Administrative Hearings using any of the following: • Electronically: https://portal.azoah.com/submission/ • In-Person or by Mail: 1740 West Adams Street, Lower Level, Phoenix, Arizona 85007

EXCHANGING DISCLOSURE STATEMENTS AND EXHIBITS Under A.A.C. R4-9-118(B) (effective November 5, 2017), a party to the hearing must serve on every other party and file with the Office of Administrative Hearings a copy of: • The disclosure statement; and, • Any exhibit that the party will use at the hearing. Service: The disclosure statement and exhibits must be served on all parties in accordance with Arizona Administrative Code R2-19-108 Filing Documents. Under A.A.C. R2-19-108, service is completed by: • Personal delivery; • 1st class, certified or express mail; or • Facsimile. Timing: The disclosure statement and the exhibits must be served and filed not less than seven calendar days before the date of the hearing. Under A.A.C. R2-19-108, a document is served on a party: • On the date it is personally served; • Five days after it is mailed by express or 1st class mail; • On the date of the return receipt if it is mailed by certified mail; or • On the date indicated on the facsimile transmission.

CONSEQUENCES FOR FAILING TO DISCLOSE Under A.A.C. R4-9-108(C), if a witness or an exhibit is not timely disclosed as required the rules, and good cause for the failure to disclose is not shown, then the administrative law judge may: • Order that certain witnesses or exhibits not be used at the hearing; • Order that a particular fact is or is not established for the record; or, • Order that a charge, a defense, a claim, or some portion thereof, be dismissed.

Form RC-L-800A Prehearing Disclosure Statement Rev. 10/08/2019 Instructions Form PREHEARING DISCLOSURE STATEMENT FORM RC-L-800A

PART 1: WITNESS LIST DOCKET NO. Under A.A.C. R4-9-118(A), before a hearing, a party must prepare a disclosure statement containing a list of all the witnesses the party will call to testify, including the witnesses’ contact information and a brief description of the subject matter of the witnesses’ expected testimony. If you need additional space to list all witnesses, complete and attach additional Witness Lists. Example 1. Name 2. Telephone Number 3. Email Address

John Doe (123) 456-7890 [email redacted] 4. Subject Matter of Expected Testimony

John Doe will testify regarding the poor workmanship and poor installation of the Garage Door. Mr. Doe will also testify regarding the invoices and change orders for the project.

Witness 1. Name 2. Telephone Number 3. Email Address

4. Subject Matter of Expected Testimony

Witness 1. Name 2. Telephone Number 3. Email Address

4. Subject Matter of Expected Testimony

Witness 1. Name 2. Telephone Number 3. Email Address

4. Subject Matter of Expected Testimony

Witness 1. Name 2. Telephone Number 3. Email Address

4. Subject Matter of Expected Testimony

Form RC-L-800A Prehearing Disclosure Statement Rev. 1/15/2019 Page 1 of 3 PART 2: EXHIBIT LIST DOCKET NO. Under A.A.C. R4-9-118(A), before a hearing, a party must prepare a disclosure statement containing a list of all the exhibits that the party will use at the hearing. Note: All exhibits listed below must be provided to all parties to the hearing. See A.A.C. R4-9-118(B). If you need additional space to list all witnesses, complete and attach additional Exhibit Lists. Example Contract for new garage door. Invoice #10001 – Cost for garage door replacement.

Exhibit Exhibit Name

Form RC-L-800A Prehearing Disclosure Statement Rev. 1/15/2019 Page 2 of 3 PART 3: ACKNOWLEDGEMENT & SIGNATURE I certify that the above information is true and correct and that I will serve a copy of this disclosure statement and any exhibits listed in Part 2 to all parties to the hearing in accordance with A.A.C. R4-9-118. I acknowledge and understand that if I fail to properly disclose a witness or exhibit, the administrative law judge may: • Order that certain witnesses or exhibits not be used at the hearing; • Order that a particular fact is or is not established for the record; or, • Order that a charge, a defense, a claim, or some portion thereof, be dismissed.

I am the (check one):  Complainant  Respondent Docket No.

Print Name Signature Date

Form RC-L-800A Prehearing Disclosure Statement Rev. 1/15/2019 Page 3 of 3