Contract - Texas Materials - 11/14/2019 Page I of.33
Contract Quantity Adjustment/Change Order
rev,0$/12
Department: Transportation Department
Project
Name: City of Round Rock SMP-6 Date: 10/8/19
City Project Change Order/Quantity
ID Number Adjustment No. 1
Justification
Adjustment in edge and surface milling quantities for SMP-6
SUMMARY Amount %Change
Original Contract Price:
$3,852,000.00
Previous Quantity Adjustment(s):
This Quantity Adjustment: $339,274.28.
Total Quantity Adjustment(s): $339,274.28
4 't
Total Contract Price with Quantity Adjustment(s): $4,191,274.28
Previous Change Order(s): 0.00
This Change Order: 0.00
Total Change Order(s)To Date: $0.00 0.00
Adjusted Contract Price [Original Contract Price Plus r
Quantity Adjustment(s)Plus Change Order(s)]: $4,191,274,2$
Difference between Original and Adjusted Contract Prices: $339,274.28
Original Contract Time: qQ c ►ys
Time Adjustment by previous Quan.Adj./Change Order:
Time Adjustment by this Quan.Adj./Change Order: yg
New Contract Time: 0 �r5
ued for.A�prrav�
Prepared B Travis King,Project Manager,Texas Materials 10/8/19
\J Si ePrinted NameTitle,e, mpany Date
r-
i
Contractor:
Signature Printed Name,Title,Company Date
City Project _
Manager: fse e;tJt-
ign tur fPrinted Name,TitIQ U Date
Mayor �
Manager/City
Signa re Printed Name,Title Date
. Page 2 a*3
Contract Quantity Adjustment/Change Order
RW KD ROCK TF7..ti
rev,
Project Name: City of Round Rock SMP-6
Quan. Adj./Change Order No.: 1
Change Order Data
Contract
Time
Adjustment
Item # Item Description Unit Qty. Unit Price Amount (Davs)
$0.00
$0.00
$0.00
$0.00
I $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
j $0.00
TOTALS: $0.00 0
Page 3 of 3
Contract Quantity Adjustment/Change Order
'ROUND RO *,T
cev,08/12
Project Name: City of Round Rock SMP-6
Quan.Adj./Change Order No.: 1
Quantity Adjustment Data
ori,
Contract
Time
Bid Item # Item Description Unit Qty. Unit Price Amount Adjustment
4 Edge Milling 6'wide SY 140,867.62 $1.30 $183,127.91
5 Surface Milling SY 82,182.30 81.90 51561146.37
$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
$0.001
50.00
$0.00
TOTALS: --t,339,274.28 D
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
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. 2019-555138
Texas Materials Group, Inc
Cedar Park,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 10/24/2019
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
City of Round Rock Overlay Project
Nature of interest
4
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
CRH Americas Materials, Inc Atlanta, GA United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
M name is Nickole Carpenter
My , and my date of birth is
My address is 1320 Arrow Point Dr.#600 Cedar Park TX 78613 USA
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in Williamson County, State of Texas on the 24 day of October ,20 19
(month) (year)
2019.10.24
13:46:51 -05'00'
Signature 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 1.295
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. 2019-555138
Texas Materials Group, Inc
Cedar Park,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 10/24/2019
being filed.
City of Round Rock Date Acknowledged:
11/07/2019
g 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
City of Round Rock Overlay Project
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
CRH Americas Materials, Inc Atlanta, GA 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