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Contract - T. Gray Utility and Rehab - 1/14/2021Contract Quantity Adjustment/Change Order �ROUNO ROCKI F-)(Av) OUNO n ru4- palulm." a HHfifip-, And F vinnnmo h4l qArvirpe, Project flage I ot'3 Z:? Name: Basin 2 and 3, 1 Date: 12/2/20 cle.3 Manhole Rehabilitation City Project Change Order/Quantity ID Number Adjustment No, Vendor Gray Utility & Rehab Co. 5039 Steffani Lane, Houston, "rexas/8676 Company Name Address Phone No. lactifiratinn the purpose of this change order is due to minor adjustments that were required and no longer required for this project. Days have also been idjUsted due to COVID-19, rain and field octiflicts. SUMMARY Original Contract Price: Previous Quantity Adjustment(s): This Quantity Adjustment: Total Quantity Adjustrnent(s): Total Contract Price with Quantity Adjustment(s). Previous Change Order(s): This Change Order: 'rotai Change Order(s) To Date: Adjusted Contract Price (Original Contract Price Plus Quantity AdjLlStrnent(s) Plus Change Order(s)]: Difference between Original and Adjusted Contract Prices: Original Contract Time: 120 Amount a/o Change 0% $0.00 0% $0.00 0% ..... ............ .............. ...... ............... .. .......... . ...... .. . ..... ....... F: x .. ....... .... . $245,209.94 -$154,293.06 Time Adjustment t.)y previous Quan, Adj,/Change Order, Time Adjustment by this Quan. Adj./Change Order: 250 New Contract Time: 370 . ... .... ..... ........... .... ........... . ............ . .... ..... ...... ...... .... ............. ... .... .......... ........ ... ....... Vmv P df: ,: .. ........... City Project er. kjan Mardnez, Engineer Associate, CuRR 12/4/ 20 ............ . . . . . . . ................... ............. ,0000000�7 W Title Date Printed Name, PCrirntecol 4NtI-nme,!TitlC Mayor/City Mana(.'I er natu re K �Zl�ol� Date Project Name: Basin 2 and 3, Cycle 3 Manhole Rehabilitation Quan. Ad),/Change Order No.: 1 Chan e Order Data........................ ------ --- ---- ------------ ............ .......... ......... .......... .... ......... ... ... .... ............... .................... ........ ...... ............... . ......... .. ........ ........... .. .. ...... .................. ..... ......... .. .................... ................. . ........ ......... . .......... .. . ......... .......... .................... . . ... . ........ ....... ....................... .............. . . . ...... . ........ :... ..... . .% ............. .. --- ---------------- .. ..... .. Contract Time Adjustment Item # Item Description UnitQtYv Unit PrIce AF-I&Iount------- fpovs) ------------ ....... .... .......... ......... .. .............. ... ... ..... .. . .. .......... ........... ........... . ............ . .. ......... ..... .......... - - --- ---- ----- ----- �o:oo ----------------- -------------------------------- ---- --------------- ---------------------------- ---------------- $0400 �o.00 ---- - ----------------- - - $o.00 - -------------------------- $-OX00 $ 0*00 ---- --------- --------------- WWWWWWOWN0 C -------- -- ------------------ ----------- ---- ------------- -------------- ---------- ------ ---- ------------------- ------- $0400 -------- ---------- --- ------- $ 0 too -----NRRRppq FPC ------------------------------- P a R A 0 0 1 i A 0 F. i 0 P ---------------- ----------- MOM Wemk" $0000 $ 0000 ------------ -------------- -- ---- --- ------ $0000 $0400 pF ?-M-qpp1FF.Fp--- ki ...... MOM - h --- -- - -------------- -- ----- - --------- ------------------ -------------------------------------------------- --------- - --------------------- ------ ---- - --------- $4,00 --- - - -- - ---------- ------ - ----------------------------------- ---------------- - - ------ $p.f}0 $a.ao ---- - - ---- ---------- --------------- -- ------------ -------------------------------------------- F P 4 RA R M A 0 C F.F P M F MAM MR RRAgmac ho --- ------- A � A PA q 0 4 A X F A R ---------- --------------- ------------------------- ------------- --------------- ------------ ---- ------- ------- ----- --------- ----- ----- --------------- ------ - ------ $a.oa -- ------------- .... . ....... . ... ............ �o.ao $o.00 - ---------------------- ------------------- ------ -- ----------- ----------- 0600 --- ---- -------- "O"Oomen NOW ----------------- -- - ------------------ ----------------------------------------------- - ------------- --------------------------------------------------- ------------- ---------------- �o.00 $o.00 $o.00 �o.ao wwwwwkft kw-ww- 4M A pa R K R R R FUR R ROMW $0.04 $A.00 -------------------- --------- r -------------- ----------- .. . ....... ............. ............... ..... . .... .... . . ................... NO . . ...... .......... . ................. ... ..................... ------------- LS $-0600 ------------ Pro)ect Name: Basin Z and 3, Cycle 3 Manhole Rehaailitation Quan. Adj.jChange Order No.: Bid Item # Item Description . ......... .. ............. ..... .. ... ... ........... . .............. ... .......... ...... . . . . . ........ .... .......... .......... ... .... ..... .. . .......... ........ ............. ................ %.*..V..*..,...*..,- ........ .. ............. : ......... ........ ............. . ......... ...... . . .............. .. ..... .. .. ........ ....... .. .. .. . .............................. ........... ............ .... .. ............. ................ ......... . ........ ..... . .... ........... V"%*............. .... ........ .... ...... ....... ........... . ..... ................................ ....................... ..... :::..: --- ... .... ........ ............ ....... ................ ... . . . ................................ ... ....... . . ..... ..... ............... --------- ------------------- 4.8 - -------------------- ------------ - 2 TRAFFIC CONTROL4 ERROSION CONTROL---------------— - --- --------------- ------------------- --------------- 5 ----------- VACUUM 1ESTING 6 REPlACE MANHOLE CONE —NON PAVED ------------ MOV000OW" 7 REPLACE MANHOLE CONI-PAVED i ualititv Adiustment Data Unit IQtY*I Unit Price AmountI c.s soo.uo LS 1 6wo $1,Spp.00 ---- --------- - 115004600 EA 44S 125.00EA 100600 ------$3,000v00 EA $4,340.Q0 44,300.00 Aoft Contract Tune Adjustment I'lagire. .3 of - - - - - - - - - - - - - - - - - - --------------- - --------- --------------- --------------MANHOLESENCH/TROUGH - - - - - - - - - - - - - - - - --------- EA --- - - - - - - - - - - - - - - - - - - - - - - - - - - --------- - p1m I A A I : 6 - . - - - - - - --------------------- 44 ---------- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - 1 lom A 0 A 40 m ---- ---- $600,100 :14400*00REPAIR- g ADD 2FT RISERS - - ----------- - - - - - - - - - - - - - - - - EA I - - - - - - - - - - - - - - $4**000,,00 - - - - - - - - - - .:14COOO*00 A F 0 0 p M 10 INSTALL BOLTS AND GASKETS ----------- -400000000cm -- ------- EA ----------- 2 150OX001000.40 ------ ---- REPLACE AD7UST/MANHOLE FRAME NONm00 EJ% 3 -- ------- ---- ---------- 4aPAYED 3000000 REPLACE ADJUSTIMANHOLE FRAME PAVED lz - ------------- EA 107900A0300.001 ------------- — -------- ---- 13 INSTALL INTERNAL CNIMMNEYSEAI EA vow ON %02 $ IL 000*00 I2000000 Is REPLACE COVERJFRAMEJSEAL-PAVED ----- ---- I--------- ------ ---------------------- -------- EA - ----------- -9 - ------------- A A --- A A $2 i0D.00 ------------ ----------------------------- 00001 ---------------- 16 CEMEN7ITYOUS COATING --------- --- - -------------------------- yp ------ ------ o*271.42 -------- ---------- 593.00 ------- mJ251242*06 ------- ----------- - ------------------------- 17 EPDXY COATING VF I ^273.4 155.oa .4.41377v00 -----------------------------GROUT 19 LOWER. 18" OF MANHOLE EA 5 $320*0-0 19 GROUT WALL JOINTSr P PE SEALS EA a&2 1425*00 COMPLETE MANHOLE REHAB -m NON PAVED6 ---------- --------- ---------------- - — - ----- ---- - ------------------------------------------------------------ ------ ----- s ftEA$300*00------- ---------- ------ - -- --- ----- ----------- 828 --- - ------- $,580420 — -------------- - ------------------------------------- WWWWWWW 21 - - -------- COMPLETE MANHOLE REHAB,* PAVED -- ------------- - --------------- --------- EA -V3.82 --- ------ - - ------- �1450oOO ---------- mpgacelifligme A Rem ---------------- 519.00 ------------- - - ---------- ---- -------------------------------- MAP 0.00 --------------- - ----- ----- ------------ ----------------- ---------- ----------------- --------------- --------------- - -------------- $0400 ------------------- ---- -------------- - -- -------------- ---------- mm a.ao ----------------- ")0*000000"Mm.. -- ------------ q- ---------- --------------- ..... ... ---------------- ...... auo ----------------------------------------- - ------------ - -- O.OD - - - - ------------------ ---------------------------------------- ------ -K - ------------------- ---- - ------- ------------ ----- - ---------- --------------- --------------- -------------------- $0000 ---------------- - ----------------------- m-MARAMA -------- emmommm ----------------------- --------- -- ------------- ------ ------- A P I m P P A A m P A A A -------------- ------ .......... .. ........... .......... ................ 0.00 --- DOW ........... -------- ------- .... ......... ............. ....... ........ ...... .. a-:t ...... ------ --- - ---- T ------ A ..... . ... ..... ... CERTIFICATE OF fNTER.ES-TE'D,PART 1ES 1MW.0 K M Sati Complete Nos,. i • 4 and 6 if there'are interested parties. ONLY OFFICE USE1. Complete Nos. i, 21.21 5, and 6 if there 2ue no interested parties. CERTIFICATION OF FILING. 1 Name of business entity filing form, and the city, stat''e and country 0f. the business entity's place terd ficate Number: of business., 2020-70164 1 T. GRAY UTILITY & REHAB .00. press,..TX'UnitedStatas Date'TwIled. 2-. Name..0tgovemmeirt entity or state agency at s a party. to,the contract or ch the iorms Z 2/ZS/7a20 being filed. City of Rou'nd Rock, Texas Date Ac.'.knowledo'ed: g Provide the identification number used Oy,the governmental entity.:or state,agency to.. tracFEW ----- .11111"7 k or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract. QA. Na, 1 Basin 2 and 3,.Cycle'3 Manhole Rehab - QA No., 1 filature of interest 4 Name of Interested Party city, State, Country (place.of business) (chock Appilcable) ControllIn Intermedi.ary Tarnez, Marcus MPM MOWN 1::::ypress, TX:United States K 5 room ".MW Check only if there is NO Interested Party. Gi UrN'WORN DECLARAT'ON-. my date of bi►th is My name is and My address is - _F___ _. Impolklift ---------- _-- f (sheet) 1;H) (elate) (zip code) (co n Y) declare under penalY.(fr p jury that the foregoing is true and correct. I. ' cdu State of on the day of- 20. Executed in' n. y# - - - - - - - - - - - - - - , , CERTIFICATE OF INTERESTED PARTIES FORM 1295 10fl Complete Nos. 1- 4 and 6 if there are interested parties. OFFICE USE ONLY Complete Nos, 1, 21 39 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. 2020-701641 T. GRAY UTILITY & REHAB CO. Cypress, TX United States gate Filed: 2 Name of governmental entity or state agency that is a party to the contract for which the form is 12/28/2020 being filed. City of Round Rock, Texas Date Acknowledged: 01/05/2021 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. QA No. 1 Basin 2 and 3, Cycle 3 Manhole Rehab - QA No. 1 4 Name of Interested Party City, State, Country (place of business) Nature of interest (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 Vl,lcd34673b