Contract - T. Gray Utility & Rehab Co. - 1/24/2019 4 Page l of 3
Contract Quantity Adjustment/Change Order
ROUND ROCK re xns
rev,01/16
Department: Utilities and Environmental Services
Project 2016Wastewater Collection System Rehabilitation-Manhole Rehabilitation,Open
Name: Cut,and Point Repairs Date: 1/3/19
City Project Change Order/Quantity
ID Number RHB16 Adjustment No. 3
Vendor T Gray Utility&Rehab Co., LLC P.0. Box 2176-Cypress,Texas 77410 281-455-0899
Company Name Address Phone No.
Justification
Quantity Adjustment/Change Order#3 is needed for Quantity Adjustment items overage in Bid list.
SUMMARY Amount %Change
Original Contract Price: $1,362,800.00
Previous Quantity Adjustment(s): $0.00
This Quantity Adjustment: $95,151.00 '`
Total Quantity Adjustment(s): $95,151.00
Total Contract Price with Quantity Adjustment(s): $1,457,951.00
Previous Change Order(s): $72,250.00 50/a
This Change Order: $0.00 00/0
Total Change Order(s)To Date: $72,250.00 5%
Adjusted Contract Price [Original Contract Price Plus
Quantity Adjustment(s)Plus Change Order(s)]: $1,530,201.00
orm",
Difference between Original and Adjusted Contract Prices: $167,401.00
Original Contract Time: 180
Time Adjustment by previous Quan.Adj./Change Order: 30
Time Adjustment by this Quan.Adj./Change Order: 0
New Contract Time: 210
Submitted for Apprgyall
Prepared By: Wk Eddie Zapata,Senior Project Manager 1/7/19
Signature Printed Name Title 11,Com an y Date
Appro a s
Contractor: `>' ,, ti' Gerald Hoffpauir,Project Manager d�{ 1 c�
Signature UU Printed Name,Title,Company Date
City Project f,/f
Manager: c:(C,t iglq�� Eddie Zapata,Senior Project Manager 1/7/19
Signa aU IPrinted Name,Title Date
Mayor/City CrA 1A
Manager l '
Signat a Printed Name,Title Date
UN -W'�q
Page 2 of 3
Contract Quantity Adjustment/Change Order
ROUND RUCK tE)(Ab
rev,01/16
2016Wastewater Collection System Rehabilitation- Manhole Rehabilitation,Open Cut,
Project Name: and Point Repairs
Quan. Adj./Change Order No.: 3
Change Order Data
Contract
Time
Adjustment
Item # Item Description Unit Qty. Unit Price Amount
(Davs)
$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• 0.001 0
a
Page 3 of 3
Contract Quantity Adjustment/Change Order
ROUND ROCX It,XA,
rev,01/16
2016Wastewater Collection System Rehabilitation- Manhole Rehabilitation,Open Cut,
Project Name: and Point Repairs
Quan.Adj./Change Order No.: 3
Quantity Adjustment Data
Contract
Time
Bid Item # Item Description Unit Qty. Unit Price Amount Adjustment
20 Remove and Replace 6-inch Service Line LF 303 $78.00 $23,634.00
21 Install new 6-inch Service Line Cleanout EA 22 $1,685.00 $37,070.00
30 Point Repair EA 7.00 $4,921.00 $34,447.00
$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: $95,151.001 0
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
10f1
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 business. Certificate Number:
T.Gray Utility&Rehab Co., LLC
2019-439979
Cypress, TX United States Date tiled:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 01/09/2019
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-QUANTITY OVERUN
2016 WW Collection System Rehab: Manhole Rehab, Point Repairs 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 Marcus E. Tamez and my date of birth is 05/30/1977
My address is 15519 Stiller Park Dr. Cypress TX 77429 USA
(street) cit --M-..—_�_.__
(city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct,
Executed in Harris County, StaMofTexas___. --------- ,the- ---- ay of January_ ,2019
(month) (year)
V�
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.28ab6150
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. 2019-439979
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 01/09/2019
being filed.
City of Round Rock,Texas Date Acknowledged:
01/24/2019
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.
CHANGE ORDER-QUANTITY OVERUN
2016 WW Collection System Rehab: Manhole Rehab, Point Repairs 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)
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 V1.1.28ab6150