Contract - Lone Star Paving - 10/12/2017 Page 1 of 3
- Contract Quantity Adjustment/Change Order
ROUND ROCK"rEXA5
rev,01/16
Department: Transportation
Project
Name: Forest Creek Golf Course Parking Lot Overlay Date: 0/Z9/1-7
City Project Change Order/Quantity
ID Number Adjustment No. 1
Vendor Lone Star Paving 11625 Jollyville Rd. Ste 150 Austin,TX 78759
Company Name Address Phone No.
Justification
Quantity Adjustment/Change Order No. 1 is the final quantity adjustment to reflect actual placed quantities for the project close out. These
quantity adjustments are the result of deductions found during the project's completion.This QA/CO #1 has deductions for Machine Laid Type D-
HMAC(RAP) Overlay, Nominal 1.5", Including Tack for$50,960.43, Glassgrid 8511 Pavement Reinforcement Grid for$11,870.25 and Erosion
Control for$1,850.00. QA/CO #1 total is-$64,680.68.
SUMMARY Amount % Change
i
Original Contract Price: $166,045.00
Previous Quantity Adjustment(s):
Thisuanti Adjustment:
Q tY ] -$64,680.68
Total Quantity Adjustment(s): -$64,680.68
Total Contract Price with Quantity Adjustment(s): $101,364.32
Previous Change Order(s): 0%
This Change Order: $0.00 0%
Total Change Order(s)To Date: $0.00 0%
Adjusted Contract Price [Original Contract Price Plus
Quantity Adjustment(s) Plus Change Order(s)]: $101,364.32
Difference between Original and Adjusted Contract Prices: -$64,680.68
Original Contract Time:
Time Adjustment by previous Quan.Adj./Change Order:
Time Adjustment by this Quan.Adj./Change Order:
New Contract Time: 0
Submitted for Approval
Prepared By: Randy Crum, Project Manager, City of Round Rock 8/17/17
Signature Printed Name,Title, Company Date
Approvals
Contractor:
S nature Printed N me,Title, Company e
City Project
Manager: Randy Crum, Project Manager,City of Round Rock 8/17/17
Sig ture Printed Name,Title Date
Mayor/City mwah
10. (.- 47,.( lManager 04 t4
Sig tur Printed NAme,Title Date
Page 2 of 3
Contract Quantity Adjustment/Change Order
ROUND RoacrEXAS
rev,01/16
Project Name: Forest Creek Golf Course Parking Lot Overlay
Quan. Adj./Change Order No.: 1
Change Order Data
Contract
Time
Adjustment
Item # Item Description Unit Qty. Unit Price Amount (Days)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTALS: 0.00 0
Page 3 of 3
Contract Quantity Adjustment/Change Order
ROUN❑ROGC TEXAS
r
rev,01/16
Project Name: Forest Creek Golf Course Parking Lot Overlay
Quan. Adj./Change Order No.: 1
Quantity Adjustment Data
Contract
Time
Adjustment
Bid Item # Item Description Unit Qty. Unit Price Amount (navc)
Machine Laid Type D-HMAC(RAP)
1 Overlay, Nominal 1.5", Including Tack TON -473.39 $107.65 -$50,960.43
Glassgrid 8511 Pavement Reinforcement
2 Grid SY -1225 $9.69 -$11,870.25
3 Erosion Control LS -1 $1,850.00 -$1,850.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
TOTALS: -$64,680.68 0
CERTIFICATE OF INTERESTED PARTIES FORM 1295
1 of 2
Complete Nos.1.-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos,1,2,3,5,and 6 if there are no interested parties, CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 201.7-264637
Asphalt Inc.,LLC dba Lone Star Paving Company
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 09/25/2017
being filed.
City of Round Rock Date Acknowledged:
I
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract,
Forest Creek Golf Crs Overlay .
Change Order#1 Forest Creek Golf Course Overlay
4 Nature of interest #
Name of Interested Party City,State,Country(place of business) (check applicable)
Controiiing Intermediary
Kaitlin Wheeler Heritage Trust Austin,TX United States X
Preferred Materials Round Rock,TX United States X
I(
Nolan Wheeler Heritage Trust Austin,TX United States X
Patrick Wheeler Heritage Trust Austin,TX United States X
Knox,Allen Austin,TX United States X
Carroll,Brian Temple,TX United States X
Carroll, Ben San Antonio,TX United States X
Ohlendorf,Ryan San Antonio,TX United States X l
Cabaza,Aaron AUSTIN,TX United States X
Spinn,Steve Austin,TX United States X f
Wheeler,John Austin,TX United States X
Lundquist,Dean Leander,TX United States X
i
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.3337
CERTIFICATE OF INTERESTED PARTIES FORM 1295
2 of 2 u
Complete Nos,1.-4 and 6 it there are interested parties. OFFICE USE ONLY .
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 201.7-264637
Asphalt Inc.,LLC dba Lone Star Paving Company
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 09/25/2017
being filed.
City of Round Rock Date Acknowledged:
s
t
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
Forest Creek Golf Crs Overlay
Change Order#1 Forest Creek Golf Course Overlay
Y
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
r
Controlling Intermediary
i
s
S
i
i
I
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I
i
5 Check only if there is NO Interested Party.
6 AFFIDAVIT �
I swear,or affirm,under penalty of perjury,that the above disclosure is true and correct. 1
```N{�itiurr� TRACY L GAINEY
FAY PVA
Notary Public,State of Texas
=Q Comm.Expires 02-03-2019
Notary ID 130101860 Signa r of authorized agent of contracting business entity
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AFFIX NOTARY STAMP 1 SEAL ABOVE i
Sworn to and subscribed before me,by the said �L= Z ffa 4) �cx`c ,this the_ �/ �C day of 1
2017 _,to certify which,witness my hand and seal of office.
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Signatu e of officer administ ing oath Printed name of officer administering oath Title of officer 6dministering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.3337
CERTIFICATE OF INTERESTED PARTIES FORM 1295
1of2
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2017-264637
Asphalt Inc., LLC dba Lone Star Paving Company
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 09/25/2017
being filed.
City of Round Rock Date Acknowledged:
09/25/2017
g Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
Forest Creek Golf Crs Overlay
Change Order#1 Forest Creek Golf Course Overlay
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Kaitlin Wheeler Heritage Trust Austin,TX United States X
Preferred Materials Round Rock,TX United States X
Nolan Wheeler Heritage Trust Austin,TX United States X
Patrick Wheeler Heritage Trust Austin,TX United States X
Knox,Allen Austin,TX United States X
Carroll, Brian Temple,TX United States X
Carroll, Ben San Antonio,TX United States X
Ohlendorf, Ryan San Antonio,TX United States X
Cabaza,Aaron AUSTIN,TX United States X
Spinn, Steve Austin,TX United States X
Wheeler,John Austin,TX United States X
Lundquist, Dean Leander,TX United States X
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.3337
CERTIFICATE OF INTERESTED PARTIES FORM 3.295
2 of 2
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2017-264637
Asphalt Inc., LLC dba Lone Star Paving Company
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 09/25/2017
being filed.
City of Round Rock Date Acknowledged:
09/25/2017
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
Forest Creek Golf Crs Overlay
Change Order#1 Forest Creek Golf Course Overlay
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
5 Check only if there is NO Interested Party. ❑
6 AFFIDAVIT I swear,or affirm,under penalty of perjury,that the above disclosure is true and correct.
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP/SEAL ABOVE
Sworn to and subscribed before me,by the said this the day of
20 ,to certify which,witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.3337