Contract - Texas Materials Group - 2/25/2021 Page I of 3
Contract Quantity Adjustment/Change Order
ROUND ROCK I[n:�
rev,01 16
Department: Transporation Department
Project
Name: CORR SMP Arterial A 2020 Date: 1/25/21
City Project Change Order/Quantity
ID Number Adjustment No. 1
Vendor Texas Materials Group 1320 Arrow Point Drive, Suite 600 Cedar Park,Tx 78613 512-861-7100
Company Name Address Phone No.
Justification
SUMMARY Amount % Change
Original Contract Price: $4,592,087.75
Previous Quantity Adjustment(s):
This Quantity Adjustment: $163,308.02
Total Quantity Adjustment(s): $163,308.02
Total Contract Price with Quantity Adjustment(s): $4,755,395.77
Previous Change Order(s): 0%
This Change Order: $0.00 0%
Total Change Order(s)To Date: $0.00 0%
Adjusted Contract Price [Original Contract Price Plus
Quantity Adjustment(s)Plus Change Order(s)]: $4,755,395.77
Difference between Original and Adjusted Contract Prices: $163,308.02
Original Contract Time:
Time Adjustment by previous Quan.Adj./Change Order:
Time Adjustment by this Quan.Adj./Change Order:
New Contract Time: 0
Submitted for Approval
Prepared By: Travis King E „ Travis King, Project Manager,Texas Materials 1/25/21
Signature Printed Name,Title, Company Date
Approvals
Orion Fox V' US.E,=b.,®'e.asma•e.
Ma male •Onon .
Contractor: — 0 25„Ch595-0Fo'9 Orion Fox, Operations Manager,Texas Materials 1/25/21
Signature Printed Name,Title,Company Date
City Project S. 11
Manager: /� ovtiTtlo .l Ss.auG rn I Z
Si ature Printed Name,T& Date
Mayor/City
Manager -2 I
Sigp tLIre Printed Name,Title Date
R-2021 -n 5g
Page 2of3
Contract Quantity Adjustment/Change Order
ROUND POCK I i.' `.
rev,01/16
Project Name: CORR SMP Arterial A 2020
Quan. Adj./Change Order No.: 1
Change Order Data
Contract
Time
Adjustment
Item # Item Description Unit Qty. Unit Price Amount
$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
S0.00
TOTALS: $0.001 0
Page 3 of 3
Contract Quantity Adjustment/Change Order
ROUND RDIX f i=",
rev,01 15
Project Name: CORR SMP Arterial A 2020
Quan. Adj./Change Order No.: 1
Quantity Adjustment Data
Contract
Time
Bid Item # Item Description Unit Adjustment
p Qty. Unit Price Amount
2 TY-D HMAC SURFACE COURSE TON 1902.85 $78.50 $149,373.73
$0.00
0.00
REFL PAV MRK TY 1 (W)4"
13 (BRK)(100MIL) LF 63 $0.53 $33.39
14 REFL PAV MRK TY 1-C LF 118 $3.90 $460.20
15 REFL PAV MRK TY 1 (Y)4"(SLD)(100 MIL) LF 140 $0.50 $70.00
REFL PAV MRK TY 1 (W)8"(SLD)(100
18 MIL) LF 716 $0.95 $680.20
REFL PAV MRK TY 1 (W)12"(SLD)(100
20 MIL) LF 2493 $3.00 $7,479.00
REFL PAV MRK TY 1 (Y)12"(SLD)(100
21 MIL) LF 385 $3.00 $1,155.00
REFL PAV MRK TY 1 (W)24"(SLD)(100
22 MIL) LF 703 $5.50 $3,866.50
REFL PAV MRK TY 1 (W)18"(YLD
25 TRI)(100 MIL) EA 2 $95.00 $190.00
$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: $163,308.021 0
CERTIFICATE OF INTERESTED PARTIES FORM 1295
i C-If 11
Compete Nos,I-4 and 6 if there are mteresteo paries. OFFICE USE ONLY
Complete Nos.1,2 3,5,and 6 4 there we no intereizedparies CERTIFICATION OF FILING
1 Name of business entity filing form and the city,state and country of the business entity place Certificate Nun-Aw:
of business. 2021-714441
Texas Niaterials Group,Inc
Cedar Park,TX United States Date Fded:
2 Name of governmental entity or state agency that is a R&r-ry to the contract for which the form is 02*5M21
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,
00000
QA,'CO#1 CORR 2020 SMP Arterials Project
Nature of interest
4 Marne of Interested Party City,State,Country(place of business) (emcit appilcampi
Controlling Intermediary
CRH Atlanta,GA United Stales x
5 Check only if there is NO Interested Party.
G VNSVWORN DECLARATION
myr-zvneis arid my dateoltarthis
My address is 1320 Arrow Pninr Driv,, (70flar Rift _721113—USA—
istaw) (rip C0110 icowt-P
I declare under penaly of perjury that the foregoing a true and coriect.
Executed in WH I IANISON County 1,t;lu->(A TPYA-S...........................an dw--5�1-h-day or Et<Ilnm 20-Ll—
...................-.11
Sit} u e author red
Jent of contracting business entity
Cgxih r a7r" 1
Form-,provided by Texas Ethic-,Commission my v.ethics,staie.tx,us Version V1.1,ceffd98a
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1of1
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. 2021-714441
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 02/05/2021
being filed.
City of Round Rock Date Acknowledged:
02/10/2021
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.
00000
QA/CO#1 CORR 2020 SMP Arterials Project
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
CRH 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.ceffc198a