CM-09-10-197TEXAS DEPARTMENT OF TRANSPORTATION
CONSTRUCTION CONTRACT CHANGE ORDER NUMBER: 03
Third Party Funding Notification Sheet
This form is used when the subject change order involves funding by a source other than TxDOT/U.S. DOT, and involves third
parties who are providing funding under an Advance Funding Agreement or Donation Agreement.
1. Outside funding provided by:
City of Round Rock
(Outside Entity's Legal Name)
2. Type of outside funding agreement for this change:
(X Existing
E Amended
[Check one]
New
3. Indicate the type and amount of funding:
E Fixed Price (Lump Sum) (Estimated Amount $10,423.00
IR Actual Cost
(a) Contract Items (Bid Items): $10,423.00
(b) E&C*: (a) x 11 so = /d /98.45 -
enter %
(c) Indirect Cost**: (a + b) x 0.00 = 0
enter %
TOTAL it'll L /.4,5-
CCSJ: 2211-02-015
Project: STP 2005(921)
Highway: FM 1460
County: Williamson
District: Austin
Contract
Number: 05093202
Use as needed:
I hereby acknowledge notification of the modifications
covered by this Change Order.
Name Jamesuse, RC.
*twat le—
Typed/Printed Title
*The percentage (%) for E&C (Engineering and Contingencies) charges varies from project to project
depending on the contract amount of the project. Projects with a higher contract amount will have a tower rate
of E&C charge. For a specific project, E&C rate (%) can be derived from the cost of "Engineering and Contingencies" in
the "Estimated Cost" of the project.
** Use the statewide district rate as established by Finance Division each year. This line 3(c) is for Service Project only,
unless otherwise specified in the Advance Funding Agreement. See Stand Alone Manual Notice 98-2 for instructions.
Funding for this Change Order has been arranged:
TxDOT Representative Date
Typed/Printed Name:
TXDOT Form 2146-AFA (Rev. 7/2007) Page 1 of 1
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CHANGE ORDER AMOUNT
DATE: October 7, 2009
SUBJECT: City Manager Approval — October 9, 2009
ITEM: Consider executing Change Order No. 3 with TxDOT for the FM 1460 expansion
project.
Department: Transportation Services
Staff Person: Thomas E. Word, P.E., Chief of Public Works Operations
Justification:
Change Order No. 3 with TxDOT alters the driveway to a business within the FM 1460
expansion project to provide better and safer ingress and egress. This also necessitates the
alteration of the storm sewer system in the area, providing additional pipe and 10' Type II -R
inlet. Also included is one sign for traffic control purposes. This Change Order No. 3 also moves
the storm sewer items on System 3 (3-B2 to 3-B11) to the City of Round Rock funding category.
The Advanced Funding Agreement between TxDOT and the City of Round Rock states that all
Kiphen Road construction is funded by the City of Round Rock.
Funding:
Cost: $11,621.65
Source of funds: 4B — Round Rock Transportation Development Corporation Construction
Outside Resources:
TxDOT
Background Information:
The Standard Utility Agreement and the Utility Joint Use Acknowledgement Reimbursable
Utility Adjustment with TxDOT was approved by City Manager on May 15, 2009. (CM -09-05-
088).
Public Comment:
N/A
UPDATED APRIL 2008
5/12/2009
Request for City Council/City Manager Action
City Council p City Manager
Submit completed form for all City Manager and City Council approvals.
Department Name: Transportation Services
Contact Person: Chaz Gordon /Kathy Michna
Project Mgr/Resource: sill Stablein
Project Coordinator: Tom Word, P.E.
Assigned Attorney: Stephan Sheets
City Council or City Manager Approval Date:
Agenda Wording
Project Name: FM 1460 Expansion
ContractorNendor: TxDOT
Funding Source: RR Trans Dev Corp Construction
Additional funding Source:
Amount: $
Account Number:
10/9/2009
11,621.65
Consider executing Change Order No. 3 with TxDOT for the FM 1460 expansion project.
Finance Information
CI
Is Funding Required? Yes to I No
Initial Construction Contract
Construction Contract Amendment
Change Order
Change in Quantity
ED Initial Professional Services Agreement
Q Supplemental Professional Service Agreement
Purchasing/Service Agreement
Q Purchase Order
Item(s) to be purchased
Unforeseen Circumstances
ID!
Other (Please clearly identify action on lines below)
Amount
$ 11,621.65
FINANCE
N/A Approved
fJ � Finance/CIP Date
ED a Finance/Acct Date
Purchasing Date
a Budget Date
APPROVALS
(to be completed ONLY by Finance)
Final Finance Approval Required
Approved
Finance Director Date
Once approvals have been obtained. please forward the RFA. blue sheet back up r1tormatron and orgrnals to City Secretary, Sara White.
ITEMS WILL NOT BE PLACED ON THE COUNCIL AGENDA WITHOUT FINANCE AND LEGAL APPROVAL PRIOR TO SUBMISSION.
Required for Submission of ALL City Council and City Manager Items
Project Mgr. Signature:
Dept. Director Signature:
"City Attorney Signature:
City Manager Signature:
Date:
Date:
Date:
Date:
4-_2'1-p�
5'1.7/0 i
b5
"City Attorney signature is required for all items.
REVISED 9/28/2009
LEGAL DEPARTMENT APPROVAL FOR CITY COUNCIL/CITY MANAGER ACTION
Required for Submission of ALL City Council and City Manager Items
Department Name: PW/Transportation
Project Mgr/Resource: 841 Stabiein
Council Action:
ORDINANCE
Agenda Wording
Project Name: FM 1460 Expansion
ContractorNendor: TxDOT
n RESOLUTION
nCity Manager Approval
CMA Wording
Consider executing Change Order No. 3 with TxDOT for the FM 1460 expansion project.
Attorney Approval
Attorney
Notes/Comments
Date
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Updated 6/3/08