Contract - Texas Materials Group - 1/13/2022 Page � ol,
Contract Quantity Adjustment/Change Order
MGM
'e"0 M,V,
Department-. City of Round Rock Engineering Services Division
project CORR 2021 SMP Arterials-Forest Creek, Old Settlers, Hesters Crossing, S Mays, N Mays, Paloma,
Warne: Jeffery Date: 12/9/21
Co Project Change Order/Quantity
ID Number Adjustment No, I
Vendor 1'exas Materials Group 1320 Arrow Point Dr. 4600 Cedar Park,TX (512)861-2100
Corril,mny Narne Address Phone No.
Justification
Additional work to existing sections to improve pavernent pavement quality on Hester's Crossing and Harvey Penick Drive,
SUMMARY Amount O/o Change
Original Contract Price: $3,318,
��//�i�,
Previous QUantity Adjustrrent(s); $0,00
//i
This Quantity AdjustrneniC $350,187.07
Total Quanbty Adjustruient(s): $350,187,07
Totai Contract Price with Qjantty Adjustnnenr(s)�� $3,669,046,81
Previous Change order(s): 0"r/fa
This Change Order: $0,00 0%
Total Change Order(s)"I"o Date: $0.00 011/0
Adjusted Contract Price forigniall Contract Price Plus Quari AdjusVinent(s) A
eils
MEMO,
Plus Charge Order(s)): $3,669,011,16,81
0ifferenct between Original and Adjusted Contract Paces: $350,187,07
Original Contract Tirre� 120
_I
[Ir erne Adjustment by previcus Quan.Adj./Change Order': 0
Tirne AdyUsrment by this Quan,Adj./Change Order: 17
New Convact Time: 137
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Prepared By:
Hedieh Yazdarr, Pr oject Manager, Texas Materials GrOUP 12/13/21
Signature Printed Narne,Title, Company Date
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contractor:
Signature Printed Name, Tide, Company Date
City Project 00,
Manager:
Sigfrst—Ure Printed Name, We Date
Mayor/City
Manager
siginato 111, �Prnted ae, Title dr Dia e
a—un-CC9,
Contract Quantity Adjustment/Change Order
MIX".i""
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CORR 2021 SMP Artery ais- Forest Creek, Old Settlers, Hies,ters Crossing, S Mays, N
Project Narne: Mays, Palorna,Jeffery
QUan,Ad)./Chanc e Order No, I
Charyge Order Data
'Aa
77717' 77TIZ2EL"77",7 7777 '7777=
Contract
Time
Adjustment
Item # Item Description Unit Qty. Unit(Price Amount Davs
In
ILLL
I 011� In/
r r. 4
.............
KOO
$0.00
$0.00
$0.00
$0.00
$0,00
MOO
$0,00
$0.00
!$0.00
$mo
$mo
$0,00
$0.00
$0,00
TOTALS: WOO 01
Contract Quantity Adjustment/Change Order
RIA 11 1 1,
If,
CORR 2021 SMP Arterials- Forest Creek, Od Settlers, Resters Crossing, S Mays, N
f1ro)ect NarneMays,Paloffia,Jeffery
Quan. Adj./Change Order No,: I
Quanti Adjustment Data
Contract
Time
Bid Item # Item Description Unit Qty. Unit Price Amo�unt Adjustment
7 777 '777,
1/00MENER/
6 SURFACE MILLING 2"DEPTH SY 24,271 00 $ 2,33 $56,551.43 6
3 TY D HMAC SURFACE COURSE 2" TON 2,791 16 $ 8900 $2!18,413.24 6
12 REFL PAV MR,K TY I(VV)4"BRK(100 MIL) LF I 5,551-00 $ 020 $1,110,20 0,5
13 REFL PAV MRK TY 1-C EA 114.00 S 4A4 $50&16 1
14 REFL PAV MRK TY I(Y 4"SLD(100 Mil- LF 1,424.00 $ 0.46 1 $655,04 0.5
17 REFL PAV MARK TY I 8"SLD(1 O0 MIL) LF 1,2O7.00 $ 1.02 $1,231.14 0.5
19 REFL P'AV MRK TY P 12"(SLD)(1 DOMILILF 114.00 S 357 $406.98 O's
21 REFL PAV MRK TY 11(W)24"(SLD)(100 MIL) LF 41,00 $ 9,28 $380.48 0.5
22 REFL PAV MRK TY I (W)(ARROW) 100 MIL) EA 24,00 $ 13260 $3,182.40 1
24 BARRICADES Sl(3NS AND TRAFFIC HANDLING Mo 1,00 $ 37,7547.00 $37',750,00 0
..................
TOTALS3 X87,47 17
-
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1ot1
Complete Nos.i-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
I Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number.
of business. 2021-834646
Texas Materials Group
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 forms 12/21/2021
being filed.
The 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
Change order/quantity adjustment for asphalt pavement repairs on CORR 2021 SMP Arterials project.Adjustments/extensions
on Hester's Crossing and HarmPenick Or.
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Jarma,Tim Bertram,TX United States X
Shogren,John Cedar Park,TX United States X
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is Hedieh Yazdani and my date of birth is
My address is 5604 Southwest Parkway APT 2021 Austin , TX 78735 USA
(street) (c ty) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in Fairfax county, state orVirginia
on the 21 day of Decembeg021
(month) (year)
Signature of authorized agent of contracting business entity
(Dedarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.191b5cdc
CERTIFICATE OF INTERESTED PARTIES
FORM 1.295
lofl
Complete Nos.l-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. 2021-834646
Texas Materials Group
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 Is12/21/2021
being filed.
The City of Round Rock Date Acknowledged:
01/06/2022
3 Provide the Identification number used by the governments]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
Change order/quantity adjustment for asphalt pavement repairs on CORR 2021 SMP Arterials project.Adjustments/extensions
on Hester's Crossing and Harvey Penick Dr.
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Jarma,Tim Bertram,TX United States X
Shogren,John Cedar Park,TX United States X
5 Check only if them Is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(sem) (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 V1.1.191b5cdc