Contract - Lone Star Paving - 10/24/2019 Pago 1 of 3
Contract Quantity Adjustment/Change Order
FEW
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Department: Tran$portation Department
Project 2017 SMP Residential Type F Overlay
Narne: Project 4 Date: 9/24/19
City Project Change Order/Quantity
ID Number Adjustment No. 1
Justification _
Contract Close Out
SUMMARY Amount %Change
Original Contrail Price: $5,064,U40.00'firs :
Previous Quantity Adjushatent(s): $0,00
This Quan ft Adjustrnent: -$500,780.51
Total Quantity Adjustment(s), $500,7805T
Total Contract Price with Quantity Adjustment(s): $4,563,?39.49
Previous Change Order(s): 0'Q0
This Change Order: 0.00
Total Change Order(s)To Date: $0.00 0.00
Adjusted Contract Price [Original Contract Price Plus
Quantity Adjustment(s)Plus Chance Order(s)j: $4,563,259.49
Difference between Original and Adjusted Contract Prices: $500,78051
Original Contract Time:
Tire Adjustment by previous Quan.Adj./Change Order:
Time Adjustment by this Quan,Adj./Change Order:
New Contract Time: 0
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Sl nature Printed Name,Title,Cpmpany CsJ
. elQr(. k Date
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Page 2 of 3
_ Contract Quantity Adjustment/Change Order
rev,as/12
Project Name: 2017 SMP Residential Type F Overlay Project 4
Quan.Adj./Change Order No.: 1
Change Order Data
Contract '
Time
-Adjustment
Item# Item.Description Unit Qty. Unit Price Amount (Da vs)
'� } ..' '� t 7 :: .. r�o-. s-1111 '�c'
.I s .. �^'! `3 ...a ,r ti .r, a��.c.�sY�w..6�*c®'w;'� '.m4 .-.`�%
$0.00
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$0.00
$0.00
$0.00
$0.00.
$0.00 .
$0.00
$0.00
$0.00
$0 00
. $0.00
$0.00
$0.00
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Page 3 of 3 .
Contract Quantity Adjustment/Change Order
rev,08/12
Project Name: 2017 SMP Residential Type F Overlay Project 4 .
Quan.Adj./Change Order No.: 1
Quantity Adjustment Data
�..-ro.+ - a�as*�"'q�g"'.»"'�".= Rs' _ `' � � 3. ,,g39 a:. Aa+e. . t,.,c •r+ .3.�±
Contract
Time
Bid Item# Item Description Unit Adjustment
P Qty. unit Price _ Amount
31 , Type F HMAC 1"Overlay Ton 1645.25 .$80.00 $131,620.00
2 Pavement Repair Ton 4398.05 $77.25 -$339,749.36
3 Edge Milling(6'.Wide) SY -6498 $0.50 $3,249.00
4: Surface Milling SY -13506. $1.00 -$13,506.00
5 Type D HMAC Spot level up., Ton -100 ..$110.00 $11,000.00
6 Valve Can Adjustment EA . -34 $52.00 -$1,768.00
7 Manhole Adjustment EA -51 $156.00 -$7,956.00
Remove and Replace Concrete
8 Curb/Gutter 'LF -5082 $47.00 $238,854.00
Remove and replace Reinforced Concrete
9 Driveway SF 4201 $11.50 $48,311.50
10 Remove and replace.Concrete Sidewalk SF -9319 $9.35 $87,132.65
11 Reinforced Concrete Sidewalk Ramp EA -1 $1;560.00 -$1,560.00
Remove and replace Reinforced Valley
12 Gutter SF 617 $39.00 $24,063.00
13 Traffic Control MO 0 $4,000.00 $0.00
$0.00
$0.00
$0.00
$0.00 "
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
t,� OT -$S00 780.51 0
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
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
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business.
Lone Star Paving Company 2019-551192
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a patty to the contract for which the form is 10/14/2019
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.
000000
Asphalt Paving
4 Nature of interest
Name of interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Lone Star Paving Company Austin,TX United States X
5 Check only if there is NO Interested Party.
6 UNSWORN DECLARATION
My name is_ , Sava L�f�.
and my date of birth is
My address is. t��=� Z. �_l( i lJ l L #�. J '! i_ft s{`(A_) j X , 7W7 J 07 , + S q
{steel) (city) (state)
(zip code) (country)
I declare under penalty
y—off perjury that the foregoing is true and correct. --�,r �^
Executed in t k= ( County, State of i -1� J on the 14 d y of - �?,20
(month) (year)
L
rs ignature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d
CERTIFICATE OF INTERESTED PARTIES FORM 1295
1of1
7-7
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. 2019-551192
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 10/14/2019
being filed.
City of Round Rock Date Acknowledged:
10/16/2019
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.
000000
Asphalt Paving
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Lone Star Paving Company Austin,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 V1.1.3a6aaf7d