Contract - Lone Star Paving - 1/10/2019 Page I of 3
- Contract Quantity Adjustment/Change Order
t rtOUAlrtt�C1<TEXAS
rev,01/16
Department: Transportation
Project
Name: 2017 SMP Chip Seal(University Blvd. &Deep Wood Dr.) Date: 11/28/18
City Project Change Order/Quantity
ID Number Adjustment No. 1
Vendor Lone Star Paving 11675 Jollyville Road Suite 150 Austin,TX 78759 512-428-5778
Company Name Address Phone No.
Justification
Increased tonnage(296.58 Ton)in Ty.B(12")due to widening the required area for pavement repairs on Deep Wood and University. Increased
tonnage(38.6 Ton)in Ty. D(2")due to a required level up for the Play For All Abilities new drive access. Removed 53,500 SY of chip seal never
completed due to unforeseen complication in the underlying surface courses.
SUMMARY Amount olo Change
Original Contract Price: $720,123.75
'
Previous Quantity Adjustment(s): $0.00I1
i
This Quantity Adjustment: -$97,834.68
Total Quantity Adjustment(s): -$97,834.68 j
Total Contract Price with Quantity Adjustment(s): $622,289.08
0%
Previous Change Order(s):
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)]: $622,289.08 I
Difference between Original and Adjusted Contract Prices: -$97,834.68
Original Contract Time:
Time Adjustment by previous Quan.Adj./Change Order:
Time Adjustment by this Quan.Adj./Change Order:
New Contract Time: 0
0-1-mitted for Approval
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Prepared B : a <<'l
P y y l
Signature Printed Name,Title,Company Date
Approvals
Contractor: lgvw �� �� (. L-ewonw AW10s ,
.71
ignat re Pr ted Name,Title,Company Date
City Project <—j.�. n
Manager: 19� KJ L�� ���1 C..� 1. (2 -.26 -1
Signature Printed Name,Title Date
Mayor/City ,M I
Manager A (f��- 1 9 1 q
-
Signature Printed Na e,Title t Date
*Modified by Amendment#1(R-2018-5986)
Page 2 oC 3
r�ROUND ROCH TM15
rev,01/16
Project Name: 2017 SMP Chip Seal(University Blvd. &Deep Wood Dr.)
Quan.Adj./Change Order No.: 1
Change Order Data
Contract
Time
Adjustrnent.
Items 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
_, <r
Con-�ract Qnan'l- y Adjusb—nan1-/Change Ordeo-
� QUN0rtou<7EXA5
revf 01/16
Project Name: 2017 SMP Chip Seal (University Blvd.&Deep Wood Dr.)
Quan.Adj./Change Order No.: 1
Quantity Adjustment Data
Contract
Time
Adjustment
Bid Itern 4-- Item Description Unit qty- Unit Price Amount
1 Seal Coat(Gr 5 Knippa) SY -53500 $3.10 -$165,850.00
2 12"Pavement Repair In Place TON 296.58 $177.50 $52,642.95
3 TY D 2.0"(Park&Play) TON 38.6 $108.75 $4,197.75
5 Alternate# 1-6.0"TY B Recycle Center TON 75.25 $148.50 $11,174.63
$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: -$97,834, 0
d
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1of2
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.:.,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing farm,and the city,state and country of the business entity's place Certificate Number:
of business, 2019-437975
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 01/04/2019
being filed.
City of Round Rock 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.
City of Round Rock Project
QA ICO
Nature of interest
4
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling intermediary
Carroll,Brian San Antonio,TX United States X
Carroll,Ben San Antonio,TX United States X
Condon,Josh Austin,TX United States X
Ramming,John Austin,TX United States X
Nalvar,Joe Georgetown,TX United States X
Playfair,Thomas New Braunfels,TX United States X
Ohfendorf,Ryan Austin,TX United States X
Knox,Allen Austin,TX United States X
Monsey,Greg Austin,TX United States X
Lundquist,Dean Leander,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
Nolan Wheeler Heritage Trust Austin,TX United States X
Patrick Wheeler Heritage Trust Austin,TX United States X
Kaitlin Wheeler Heritage Trust Austin,TX United States X
Asphalt Inc Employee Investments Austin,TX United States X
Preferred Materials.,Inc Round Rock,TX United States X
Forms provided by Texas Ethics Commission www.ethics.stateAx.us Version V1.0.6711
CERTIFICATE OF INTERESTED PARTIES FORM 1295
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. 2019-437975
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 01/04/2019
being filed.
City of Round Rock 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.
City of Round Rock Project
QA/CO
Nature of interest
4 Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECL N
r.
My name is �"` Z
�' '41, `"' S , and my date of birth Is �� /`� 7
Nl address is I v,..� A, t h� 7�- -7
Y
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in G �' County, State of //� ,on the / day of " .20
(month) (year)
�tf.
Si au orized agent racting business ntity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711
li
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 of Certificate Number:
business. 2019-437975
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 parry to the contract for which the form is being 01/04/2019
filed.
City of Round Rock Date Acknowledged:
01/08/2019
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.
City of Round Rock Project
QA/CO
4
Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Carroll, Brian San Antonio,TX United States X
Carroll, Ben San Antonio,TX United States X
Condon,Josh Austin,TX United States X
Ramming,John Austin,TX United States X
Naivar,Joe Georgetown,TX United States X
Playfair,Thomas New Braunfels,TX United States X
Ohlendorf, Ryan Austin,TX United States X
Knox,Allen Austin,TX United States X
Morisey, Greg Austin,TX United States X
Lundquist, Dean Leander,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
Nolan Wheeler Heritage Trust Austin,TX United States X
Patrick Wheeler Heritage Trust Austin,TX United States X
Kaitlin Wheeler Heritage Trust Austin,TX United States X
Asphalt Inc Employee Investments Austin,TX United States X
Preferred Materials., Inc Round Rock,TX United States X
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711
CERTIFICATE OF INTERESTED PARTIES FORM 1295
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 of Certificate Number:
business. 2019-437975
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 parry to the contract for which the form is being 01/04/2019
filed.
City of Round Rock Date Acknowledged:
01/08/2019
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.
City of Round Rock Project
QA/CO
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 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 V1.0.6711