Contract - T. Gray Utility & Rehab Co - 3/28/2019Page I of 4
Contract Quantity Adjustment/ Change Order
HOIIN�HOCK Irms
rev, 01/l6
Department: Utilities and Environmental Services
Project 2016Wastewater Collection System Rehabilitation - Manhole Rehabilitation, Open
Name: Cut, and Point Repairs Date: 2/25/19
City Project Change Order/Quantity
ID Number RHB16 Adjustment No. 4
Vendor T Gray Utility & Rehab Co., LLC P. O. Box 2176 - Cypress, Texas 77410 281-455-0899
Company Name Address Phone No.
Justification
quantity Aajustment / Change Order #4 is needed for final Quantity Adjustment items in Bid list.
SUMMARY
Amount % Change
Original Contract Price:
$1,362,800.00
Previous Quantity Adjustment(s):
$95,151.00;
This Quantity Adjustment:
-$91,028.23
Total Quantity Adjustment(s):
$4,122.77
Total Contract Price with Quantity Adjustment(s):
$1,366,922.77
Previous Change Order(s):
$72,250.00 5%
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)]:
$1,439,172.77
Difference between Original and Adjusted Contract Prices:
$76,372.77
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 Approval
Prepared By: ala& glork
Eddie Zapata, Senior Project Manager
2/27/19
Signature UPrinted
Name, Title, Company
Date
Approvals
Contractor: jam, P� ��
Gerald Hoffpauir, Project Manager
Z L 11 ej
Signature VV
Printed Name, Title, Company
Date
City Project
Manager: �yu '
Eddie Zapata, Senior Project Manager
2/27/19
Sig ature
Printed Name, Title
Date
Mayor/City
Manager
Craig Morgan, Mayor
?j��.
Page 2 of 4
Contract Quantity Adjustment/ Change Order
�OiINO ROCK TEXAS
rev, 01116
2016Wastewater Collection System Rehabilitation - Manhole Rehabilitation, Open Cut,
Project Name: and Point Repairs
Quan, Adj./Change Order No.: 4
Chan a Order Data
Item # Item Description Unit Qty. Unit Price Amount
Contract
Time
Adjustment
(Days)
$0.00
$0.00
$0.00
$0.00
$0.00-
$0,001
$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
l'age 3 of 4
*01— Contract Quantity Adjustment/ Change Order
ROIINCIROCK TEXAS
rev 01/16
2016Wastewater Collection System Rehabilitation - Manhole Rehabilitation, Open Cut,
Project Name: and Point Repairs
Quan. Adj./Change Order No.: 4
nuantity Adiyetmant rinta
Bid Item #
Item Description
Unit
Qty.
Unit Price
Amount
Contract
Time
Adjustment
innuci
6
Vacuum Testing of Manholes
EA
-93
$165.00
-$15,345.00
7
Repair Manhole Cone Section
EA
-9
$380.00
-$3,420.00
8
Repair Manhole Bench and Trough
EA
-15.00
$700.00
-$10,500.00
10
Replace, Adjust, & Realign Manhole
Frame
EA
-1
$1,500.00
-$1,500.00
12
Install External Chimney Seal for Manhole
EA
-3
$1,900.00
-$5,700.00
13
Install External Chimney Seal for Manhole
- Asphalt Surface
EA
-1
$3,100.00
-$3,100.00
14
Replace Manhole Cover, Frame, Frame
Seal - Lawn Surface
EA
-2
$975.00
-$1,950.00
15
Replace Manhole Cover, Frame, Frame
Seal- Asphalt Surface
EA
-7
$2,100.00
-$14,700.00
16
Replace Manhole Cover, Frame, Frame
Seal - Concrete Surface
EA
-2
$1,250.00
-$2,500.00
17
Cementitious Coating of Manhole
VF
-207.11
$93.00
-$19,261.23
18
Grout Lower 18" of Manhole
EA
6
$320.00
-$1,920.00
19
Complete Manhole Rehabilitation
VF
-95
$255.00
-$24,225.00
20
Remove and Replace 6 -inch Service Line
LF
300.5
$78.00
$23,439.00
21
Install 6 -inch Service Cleanout
EA
11
$1,685.00
$18,535.00
22
Install 6 -inch Wastewater Line by Open
cut
LF
-35
$78.00
-$2,730.00
23
Remove and Replace 6 -inch Wastewater
Line by Open Cut
LF
-80
$82.00
-$6,560.00
24
Remove 6 -inch Wastewater Line and
Replace with 8 -inch Wastewater Line
LF
-140
$149.00
-$20,860.00
25
Remove & Replace 8 -inch Wastewater
Line by Open Cut
LF
-49
$126.00
-$6,174.00
26
Remove 8 -inch Wastewater Line &
Replace with 10 -inch Wastewater Line
LF
-37
$148.00
-$5,476.00
27
Remove 10 -inch Wastewater Line &
Replace with 12 -inch Wastewater Line
LF
-108
$166.00
-$17,928.00
28
Replace/Install Internal Drop Assembly
for Manhole
EA
-2
$1,800.00
-$3,600.00
30
Point Repairs
EA
7
$4,921.00
$34,447.00
$0.00
$0.00
$0.00
$0.00
$0.00
Page d o f d
Contract Quantity Adjustment/Change Order
ROUND ROCK'fE%A5
rev, 01116
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.28ab6150
CERTIFICATE OF INTERESTED PARTIES
FORM I.295
loll
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
Certificate Number:
1
Name of business entity filing form, and the city, state and country of the business entity's place
of business.
2019-460345
T. Gray Utility & Rehab Co., LLC
Cypress, TX United States
Date Filed:
03/05/2019
2
Name of governmental entity or state agency that is a party to the contract for which the form is
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 VJW Collection System Rehab: Manhole Rehab, Point Repairs and Open -Cut
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(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 Marcus E. Tamez and my date of birth is 05/30/1977
My address is 15519 Stiller Park Dr. Cypress TX 77429 USA
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in Harris County, State of Texas n the 5th day of March , 2019 .
(year)
r(month)
W
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.28ab6150
Forms provided by Texas Ethics Commission www. ethics. state. tx.us version vl.i.zoaoolou
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
Certificate Number:
1
Name of business entity filing form, and the city, state and country of the business entity's place
of business.
2019-460345
T. Gray Utility & Rehab Co., LLC
Cypress, TX United States
Date Filed:
03/05/2019
2
Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
City of Round Rock, Texas
Date Acknowledged:
03/06/2019
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
Nature of interest
4
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 vl.i.zoaoolou