Contract - T. Gray Utility and Rehab Co - 7/12/2018 c
Page 1 of 3
..
--- Contract Quantity Adjustment/Change Order
• a,ROUND ROCK i;
rev,01/16
Department: Utilities and Environmental Services
Project 2016Wastewater Collection System Rehabilitation- Manhole Rehabilitation,Open
Name: Cut,and Point Repairs Date: 6/7/18
City Project Change Order/Quantity
ID Number RHB16 Adjustment No. 1
Vendor T Gray Utility&Rehab Co., LLC P. 0. Box 2176-Cypress,Texas 77410
281-455-0899
Company Name
Address Phone No.
Justification
r
antity Adjustment/Change Order#1 is needed for Change Order items required not in Bid list.
SUMMARY
Original Contract Price: Amount %Change
Previous Quantity Adjustment(s): $1,362,800.00
This Quantity Adjustment: $0.00
$0.00
Total Quantity Adjustment(s):
Total Contract Price with Quantity Adjustment(s): $0.00
$1,362,800.00
Previous Change Order(s): 0%
This Change Order:
$0.00
Total Change Order(s)To Date: $57,950.00 4%
Adjusted Contract Price [Original Contract Price Plus $57,950.00 4%
Quantity Adjustment(s)Plus Change Order(s)):
$1,420,750.00
Difference between Original and Adjusted Contract Prices:
$57,950,00
Original Contract Time:
Time Adjustment by previous Quan.Adj./Change Order: 180
0
Time Adjustment by this Quan.Adj./Change Order:
30
New Contract Time:
210
Submitted for Approval
Prepared
� " Eddie Zapata, Senior Project Manager 6/7/2018
Signature Printed Name,Title,Company Date
Approvals
Contractor: Gerald HofPpauir,Project Manager C y
Signature Printed Name,Title,Company
City Project Date
Manager: Eddie Zapata,Senior Project Manager
Sign re 6/7/2018
Printed Name,Title Date
Mayor/City
Manager Signat e Craig Morgan, Mayor . Z
'
Printed Name,Title Date
Page 2 of 3
Y
- Contract Quantity Adjustment/Change Order
rev,01,/16
2016Wastewater Collection System Rehabilitation- Manhole Rehabilitation,Open
Project Name: Cut,and Point Repairs
Quan.Adj./Change Order No.: 1
Change Order Data
Contract
Time
Item # Item Description Unit Adjustment
Qty. Unit Price Am®unt (Days)
Construction Entrance; Site Clearing;
CO-1 Erosion Control; Restoratoin LS 1 $7,500.00 $7,500.00 30
Reset and Reseal Manhole including
CO-2 adjustment,seal, &grout EA 3 $1,500.00 $4,500.00
Remove&Replace MH Crone Section and
CO-3 replace with 32"section EA 2 $6,500.00 $13,000.00
MH Rehabilitation with Reliner cement&
CO-4 Raven 405 EA 5 $6,000.00 $30,000.00
CO-5 Testing,Inspection, &Safety LS 1 $2,950.001 $2,950.00
$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: $57,950.00 30
Page 3 of 3
Contract Quantity Adjustment/Change Order
rev,01/1i
2016Wastewater Collection System Rehabilitation- Manhole Rehabilitation, Open
Project Name: Cut,and Point Repairs
Quan.Adj./Chanae Order No.: 1
Quantity Adjustment Data
Contract
Time
Bid Item ## Item Description Unit Qty. Unit Price Amount Adjustment
$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
CERTIFICATE OF INTERESTED PARTIES FORM 1295
lofl
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. 2018-369544
T.Gray Utility&Rehab Co., LLC
Cypress,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 06/18/2018
being filed.
City of Round Rock,Texas Date Acknowledged:
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.
CHANGE ORDER-MANHOLE REHAB
2016 WW Collection Systern Rehab: Manhole Rehab, Point Repair and Open-Cut
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling I Intermediary
Tamez,Marcus CYPRESS,TX United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is !"� �t/� � and nay date of birth is i95-/3'0//q-77IV
My address is 's 47
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Id
Executed in 4"019 County, State of o the ! day of_ L ,20_ ,
(month) (year)
ignaturof authorized agent of contras ing business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.5523
CERTIFICATE OF INTERESTED PARTIES FORM 3.295
1 of 1
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. 2018-369544
T. Gray Utility&Rehab Co., LLC
Cypress,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 06/18/2018
being filed.
City of Round Rock,Texas Date Acknowledged:
07/03/2018
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.
CHANGE ORDER-MANHOLE REHAB
2016 WW Collection System Rehab: Manhole Rehab, Point Repair and Open-Cut
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Tamez, Marcus CYPRESS,TX United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of 20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.5523