CM-2018-1914 - 10/19/2018DocuSign Envelope ID: 7EB3C9E2-64FA-43EE-BE04-OF785A4153BF
Form ROW -R-99
(Rev. 07n i)
Paye t of 1
CLAIM FOR ACTUAL MOVING EXPENSES
I. Name of Claimants)
Carlos Lopez
U Residence ® Rusin-
2. Address of Property Acquired by State:
7I2 Round Rock Ave.
Round Rock, TX 78681
4. Occupancy of Property Acquired by State
From (Date):
To (Date of Move):
2002
August 3, 2018
10 ant DO Tenant
6. Controlling Dates
Mo. I Day Yr.
a First Offer in Negotiation
2 24 t7
b. bate Property Acquired
6 30 1s
c. Date Required to Move
8 3 2018
8. Property Storage (attach explanation)
From (Date): NIA To (Date of Move): NIA
Place Stored (Name and
N/A
e All information
Pamet No: 25-02
ROW CSJ: 0681-01
3 Address Moved To:
1308 Round Rock Ave.
Round Rock. TX 76681
5. Distance Moved: 1 Milers
7. Mover's Narne and Address:
County: Williamson
Project No.: NIA
Amount of Claim:
a. Moving Expenses S6,500.00
b. Reestablishment Expenses I S It Z 3 oD . pd
c. Searching Expenses S
d. Tangible Property Loss S
C. Storage 5
1u. l cmporary Lodging (attach explanation) f. i'emooraa Lodeina
S
From (Date): NIA To (Date of MMC).
N1A g Total Amount S, 7,750.00
11. All amounts shown in Block 9 were necessary and rcamnable and are supported by attached recell1m. Pay of this claim is requested. 1 certify that f have
not submitted any other claim for, or reex ed reimbursement for, an item of expense in this claim, and that t will not accept reimbursement or
compensation fmm any other source 7jrdy�-
item of expcmc paid pursuant to this claim. l further certify that all property was moved and installed at the
address shown in Block 3, above, i� with the invoices submitted and awed terms of the move and that 411 Wbrmation submitted herewith or
included herein is true and correct/
Date of Claim- /O - "] - S Claimant
Claimant
5 new Bcdow to be Completed State
t certify that I have examined this claim and substantiating documentation attached hernvith, and have found it to be true and conect and to conform with
the applicable provisions of State law All items are considered to be necessary reasonable expenses and this claim is recommended for payment as foltaws:
Amouoror$ 7,750.00 EMMEDSEVU26–
tlocuaipnedbr.
-- 10/1I/2018 a44 NWO�t,
Dore of wn. Mon.— -
e-14- 201--/I/Y
City Manager
Laurie Hadley
I rJvl
* R 9 9 +
docuSign Envelope ID. 7EB3C9E2-64FA-43EE-BE04-OF785A4153BF
MO�►�1�
SOUTH STAR PLUMBING INC
17100 COPPERHEAD DRIVE
ROUND ROCK TEXAS IMM
JOSE TRU]ILLO {PRINc[PAL)
EMAIL-Josd223@yaboo.com
PH 512.6346437
ATTCARLOS LOPEZ (OWNER)
TAQUERIA CHAPALA
1308 ROUND ROCK AVENUE
ROUND ROCK TEXAS 78681
SCOPE OF WORK DETAILS
M-38775
SEPTEMBER 8,2018
PLUMBING TOP OUT ...................................................... .864500.00
(Extend all ventilation and water distribution for all sm1m inside the building)
PRICE BASED UPON ACCEPTANCE WFIrMG 10 DAYS
Sincerely.
]ase Truj ilio (principal)
TEXAS STATE BOARD OF PLUMBING EXAMINERS P.O.BOX 4200
AUSTIN TEXAS 78765 PH 512-436-5200
. �,,o , tq
6 1' a -,k.0(3 UX,.,,k -bu�
OlwhlS
DocuSign Envelope ID. 7EB3COE2-64FA-43EE-BE04-OF765A41538F
SOUTH
STAR PLUMBING INC
17100 COPPERHEAD DRIVE
ROUND ROCK TEXAS 78664
JOSE TRUJILLO
5126346437
joset223@yahoo.com
www.southslaiplumbing.com
EMAIL: Joset223@yahoo.com
M0BILE:572.634.6437
invoice
Bill To:
TAQUERIA CHAPALA
Invoice No: 4559
TAQUERIA CHAPALA
Date: 09/11/2018
1308 ROUND ROCK AVENUE
Terms: NET 0
ROUND ROCK TEXAS 76681
Due Date: 09/11/2018
Ship To:
TAQUERIA CHAPALA
Ship Via
1308 ROUND ROCK AVENUE
ROUND ROCK TEXAS 78681
Description
Quantity
R P. t t, Amount
DOWN PAYMENT
TAQUERIA CHAPALA
1
$7,7511.00 $7,750.00
1308 ROUND ROCK AVENUE
ROUND ROCK TEXAS 78681
PLUMBING DOWN PAYMENT $7,750.00
TOTAL CONTRACT IS $31,000.00
Parts Subtotal $7,750.00
Payment Details
Subtotal
$7,750.00
TAX 0%
$000
CHECK,CASH,CASHIERS CHECK
Shipping
$0.00
TEXAS STATE BOARD OF
PLUMBING EXAMINERS P.O.BOX 4200 AUSTIN
Total
$7,750.00
TEXAS 78765 PH 512.936.5200
PAID
$0.00
M•38775
63 Pay Now
Invoice2go ! '
Notes
PLUMBING DOWN PAYMENT $7,750.00
TOTAL CONTRACT IS $31,000.00
1!y
DocuSign Envelope ID. 7CB3CgE2-64FA43EE-BE44 OF785A4153BF
ttht'--
179
l�sfieitt3;
DocuSign Envelope ID 7EB3C9E2-64FA-43EE-BE44-OF785A4153BF
SOUTH STAR PLUMBING INC M-39775
17100 COPPERHEAD DRIVE SEPTEMBER 92018
ROUND ROCK TEXAS 78664
JOSE TRUJIL A (PRINCIPAL)
EMAIL JoscM3Qyahoo.com
PN 512634.6437
XrWARLOS LOPEZ (OWNER)
TAQUERIA CHAPALA
1308 ROUND ROCK AVENUE
ROUND ROCK' TEXAS 78681
SCOPE OF WT]RK DETAILS
TOTALWST........................ »..._.__...................._........_....»...»...$331,000.00
2 -3illo-OONCREiE SAW CIIF-CONCRETE POUR BACK -HAUL oFF..._....__.sa�oaET10 1,a.SD, oo
`7 IVeJ
UNDERGROUND PLUMBINCL............_._.__...._......_..._. »..__..__._. $7,OOD.00
(uu1stan 811 Plumbing drain lines in the ground plumbing sough)
-->750GALLONS GREASE MW ................... _....................... S6,i0Q00
Orcwgion to inSbIll new grease hp,backfill & dirt haul old
PLU(EXMBF 1 , OP OUT..._._...».............._._.»........_........._..._...................._.$4500.tA
on and water distribution for all sinks inside the building)
--jPLUMBING SET OUT FINAL ------ ------ .............................. $6
(Install all oom modes,iavatories oonnect the kichen equipment for the mw
4Q00
Restaurant and gas fines)
PRICE BASED UPON ACCEPTANCE WHITING 10 DAYS
Sincerely,
Jose Trujillo (principal)
TEXAS SPATE BOARD OF PLUMBING EXAMINERS PO BOX 4200
AUSi'IN TEXAS 78765 PH 512,936 -SM
Form 1111-9
(Rev. November 2017)
Depadmenl ol the Treasury
Inlernsl Revenue service
on your
Request for Taxpayer Give Form to the
Identification Number and Certification requester. Do not
send to the IRS.
Go to www.1rs.gov/FormW9 for Instructions and the latest Information.
2 Business name/disregarded entity name. If different from
on this fine; do not
3 Check appropriate box for fedetal lax ctasslfieation of the person whose name Is entered on line 1. Check only one of the
En following seven boxes.
C
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✓ In lvlduallsole proprietor or C Corporation S Corporation Partnership Trusuestele
El rrgle-member LLC ❑
Limited liability company. Enter the tax classification (C=C corporation, S -S corporation, PaPartnership)
Nate: Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check
LLC u the LLC Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC Is
another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, it alogia -member LLC that
is disregarded from the owner should check the appropriate bolt for the lax classification or us owner.
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s City, state, and ZIP code
4 Exemptions (codes apply only to
certain entities, not Indivkluair see
Instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
fear.. m.eunur,,nr,r.ra.e whk. rn us)
name and address (optional)
Enter your TIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid social security nun
backup withholding. For individuals, this Is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other ..
entities. It Is vour employer Identification number (EIM. Ifvou do not have a number. see Now to Det a
TIN, later. or
Note: If the account is In more than one name, see the Instructions for line 1. Also see What Name and Employer idenuflce
lVumber To Gim the Requesterfor guidelines on whose number to enter.
ODe00nn00w
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer Identification number (or I am waiting for a number to be Issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form Qf any) Indicating that I am exempt from FATCA reporting Is correct.
Certification Instructlons.You must cross out item 2 above Ifyou have been notified by the IRS lhetyou are currently subject to backup withholding because
you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition orabandonment of secured properly, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
otherthan interest and dividends, you are not required to sign the certification, but you mus( provide yourcorrecl TIN. See the Instructions forPart Il, later.
bign signature of
Here I U.S. parson►
Genera!
Instructions
Section references are to the Internal Revenue Code unless otherwise
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Future developments. For the latest information about developments
related to Form W-9 and its Instructions. such as legislation enacted
after they were published, go to www.lrs.gov/Form".
Purpose of Form
An Individual or entity (Form W-9 requester) who Is required to file an
Information return with the IRS must obtain your correct taxpayer
Identification number (TIN) which may be your social security number
(SSN). Individual taxpayer Identification number (ITIN), adoption
taxpayer Idenlitkallon number (ATiN), or employer Identification number
(EIN), to report on an Information return the amount paid to you, or other
amount reportable on an information return. Examples of Information
returns include, but are not limited to, the following.
- Form 1099 -INT pnterest earned or paid)
Date ► 811$118
- Form 1099 -DIV (dividends, including those from stocks or mutual
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CaL No. 10231X Form W-9 (Rev. 11-2017)
City of Round Rock
ROUND RACK
TEXAS Agenda Item Summary
Agenda Number:
Title: Consider approval and execution of claim forms authorizing reimbursement
of actual re-establishment expenses in the amount of $7,750.00 for the
Taqueria Chapala due to displacement of the business caused by
acquisition of right of way on the RM 620 project (Parcel 25).
Type: City Manager Item
Governing Body: City Manager Approval
Agenda Date: 10/19/2018
Dept Director: Gary Hudder
Cost: $7,750.00
Indexes: RR Transportation and Economic Development Corporation (Type B)
Attachments: 00411536.PDF, 00411529.pdf
Department: Transportation Department
Text of Legislative File CM -2018-1914
Consider approval and execution of claim forms authorizing reimbursement of actual
re-establishment expenses in the amount of $7,750.00 for the Taqueria Chapala due to
displacement of the business caused by acquisition of right of way on the RM 620 project
(Parcel 25).
This is a request for reimbursement payment to tenant for actual re-establishment
expenses. This payment is 100% reimbursable by TxDoT in connection with the RM620
project.
Cost: $7,750
Source of Funds: RR Transportation and Economic Development Corporation
City of Round Rock Page 1 Printed on 10/18/2048