Contract - Smith Contracting - 10/22/2020 Page 1 of 3
Contract Quantity Adjustment/Change Order
- ROUND ROCK IFxa•.
ev,01/16
Department: TRANSPORTATION
Project
Name: Kenney Fort Boulevard Intersection Improvements Date: 9/9/20
City Project Change Order/Quantity
ID Number Adjustment No. 2
Vendor SMITH CONTRACTING CO. INC. 15308 GINGER ST AUSTIN TX 78728 512-990-7640
Company Name Address Phone No.
Justification
Field Changes&Owner Requests
SUMMARY Amount %Change
Original Contract Price: 1 $728,995.001
Previous Quantity Adjustment(s): $25,762.00
This Quantity Adjustment: -$74,097.75
Total Quantity Adjustment(s): -$48,335.75
Total Contract Price with Quantity Adjustment(s): $680,659.25
Previous Change Order(s): $1,200.00 0%
This Change Order: $0.00
0%
Total Change Order(s)To Date: $1,200.00 0%
Adjusted Contract Price [Original Contract Price Plus
Quantity Adjustment(s)Plus Change Order(s)]: $681,859.25
Difference between Original and Adjusted Contract Prices: -$47,135.75
Original Contract Time: 180
Time Adjustment by previous Quan.Adj./Change Order: 0
Time Adjustment by this Quan.Adj./Change Order: 30
New Contract Time: 210
Submitted for Approval
Prepared By: t✓' ,L d Christopher R. Lopez, Project Manager,Smith Contracting 9/9/20
Signature Printed Name,Title, Company Date
- Approvals
Contractor: (� /�jAQ Christopher R. Lopez, Project Manager, Smith Contracting 9/9/20
Signature Printed Name,Title,Company Date
City Project
Manager: �� .� Bill Stablein, Project Manager 9'- P9-Z6
Sign ure Printed Name,Title Date
Mayor/City ,��� �
Manager � ` 1"/�
aN M 22
/� -�
Signat a Printed Ndme,Title Date
Page 2 of 3
Contract Quantity Adjustment/Change Order
rev,01/16
Project Name: Kenney Fort Boulevard Intersection Improvements
Quan. Adj./Change Order No.: 2
Change Order Data
Contract
Time
Adjustment
Item # Item Description Unit Qty. Unit Price Amount (Days)
CO-2 Contract Extension EA 1 $0.00 $0.00 30
$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 30
Page 3 of 3
.:,.:.. Contract Quantity Adjustment/Change Order
ROVND ROCK
rev,ul/Ib
Project Name: Kenney Fort Boulevard Intersection Improvements
Quan.Adj./Change Order No.: 2
Quantity Adjustment Data
Contract
Time
Adjustment
Bid Item # Item Description Unit Qty- Unit Price Amount (Days)
9 D-GR HMA(SQ)TY-C PG70-22, 2" SY -1303 $20.00 -$26,060.00
REFL PAVEMENT MARKING TY II(W)4"
15 SLD(100MIL) LF -449 $5.50 -$2,469.50
REFL PAVEMENT MARKING TY I (W)
16 ARROW(100MIL) EA -6 $165.00 -$990.00
REFL PAVEMENT MARKING TY I(W)
17 WORD(100MIL) EA -3 $220.00 -$660.00
18 REFL RAISED PAVEMENT MARKER TY I-C EA -22 $11.00 -$242.00
27 TEMP SEDMT CONT FENCE(INSTALL) LF -1760 $2.00 -$3,520.00
28 TEMP SEDMT CONT FENCE(REMOVE) LF -960 $0.30 -$288.00
31 CONDT(PVC) (SCH 80) (2") LF -104 $7.50 -$780.00
33 CONDT(PVC) (SCH 80) (3") LF -282 $10.00 -$2,820.00
35 ELEC CONDR(NO.8) BARE LF -315 $0.95 -$299.25
36 ELEC CONDR(NO.8)INSULATED LF -922 $0.95 -$875.90
40 GROUND BOX TY D(162922)W/APRON EA -2 $1,300.00 -$2,600.00
52 TRF SIG CBL(TY A)(12 AWG)(3 CONDR) EA -121 $1.10 -$133.10
61 PED POLE ASSEMBLY EA 1 $3,200.00 $3,200.00
MILLING ASPHALT CONCRETE
81 PAVEMENT(2") SY -635 $26.00 -$16,510.00
82 PRIME COAT(MC-30) GAL -127 $10.00 -$1,270.00
D-GR HMA(SQ)TY-C PG70-22 LEVEL UP
83 (2-2.5") SY -635 $28.00 -$17,780.00
$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
T15-TA-09-: 74 097.75 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 Certificate Number:
of business. 2020-673382
Smith Contracting
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 09/30/2020
being filed.
City of Round Rock Date Acknowledged:
09/30/2020
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 Kenney Fort Blvd.
Install new traffic signal and turn lanes
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.
X
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
CERTIFICATE OF INTERESTED PARTIES FORM 1295
101`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. 2020-673382
Smith Contracting
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 09/30/2020
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 Kenney Fort Blvd.
Install new traffic signal and turn lanes
Nature of interest
4
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling I Intermediary
5 Check only if there is NO Interested Party.
X
6 UNSWORN DECLARATION
My name is Christopher Lopez and my date of birth is
My address is 15308 Ginger St.
Austin TX 78728 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 30th day of September ,20 20
(month) (year)
C'v�
Signature of a th i d agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.3a6aaf7d