Contract - Capital Excavation - 9/8/2016Contract Quantity Adjustment/ Change Order
rev, 06/12
Department: Transportation
Project
Name: Creek Bend Blvd Extension
City Project
ID Number ST33CBDR
lustification
Date: 8/9/16
Change Order/Quantity
Adjustment No. 4
Page I of 3
Quantity Adjustment/Change Order #4 is required for the removal of roof and backfilling of voids 4,5, and 6 as perscribed in the plan approved by
the TCEQ. These items include flowable fill, washed pea gravel, demolition, and backfill.
SUMMARY
Amount % Change
Original Contract Price:
$8,089,168.50
Previous Quantity Adjustment(s):
$48,370.27
This Quantity Adjustment:
$29,400.00
Total Quantity Adjustment(s):
$77,770,27
Total Contract Price with Quantity Adjustment(s):
$8,166,938.77
Previous Change Order(s):
$128,583.45 0.02
This Change Order:
$67,155.80 0.01
Total Change Order(s) To Date:
$195,739.25 0.02
Adjusted Contract Price [Original Contract Price Plus Quantity
Adjustment(s) Plus Change Order(s)]:
$8,362,678.02
Difference between Original and Adjusted Contract Prices:
$273,509.52
Original Contract Time:
435
Time Adjustment by previous Quan. Adj./Change Order:
126
Time Adjustment by this Quan. Adj./Change Order:
14
New Contract Time:
575
Submitted for Approval
Prepared By: /� -
Randy Crum, Project Manager Senior, City of Round Rock 8/9/16
Signature
Printed Name, Title, Company
Date
Approvals
v
Contractor:
S' ature elf
Printed Name, Titl Company
Date
Jti
City Project
,
Manager:
Randy Crum, Project Manager Senior, City of Round Rock 8/9/16
Si ftture
Printed Name, Title
Date
Mayor/City 11�M
Manager: -/ -
U�&-(/,pvv,Wk-
9-0,�
nature
Printed Name, Title I
Date
rev, 06/12
Contract Q uantk y Adjustment/ Change Order
Project Name: Creek Bend Blvd Extension
Quan. Adj./Change Order No
Chanae Order Data
Page 2 o f 3
Item #
Item Description
Unit
Qty.
Unit Price
Amount
Contract
Time
Adjustment
(Days
1
Haul Off of Roof Material
CY
867
$20.00
$17,340.00
2
Washed 3/8" Pea Gravel
CY
511.6
$63.00
$32,230.80
3
Trackhoe
HR
65
$175.00
11,375.00
4
Loader
HR
54
$115.00
$6,210.00
$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:
$67,155.801
rev, 06/12
Contract Quantity Adjustment/ Change Order
Project Name: Creek Bend Blvd Extension
Quan. Adj./Change Order No.:
Minnfihf adiiiuct vv-nt nnf-=
Page 3 ol'3
-
Bid Item # Item ®ascription Unit Qty. Unit Price Amount
Contract
Time
Adjustment
18 Flowable Fill CY 210.00 $140.00 $29,400.00
$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: $29,400.00
0
CERTIFICATE OF INTERESTED PARTIES
Complete Nos. 1- 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Capital Excavation
Buda, TX United States
Name of governmental entity or state agency that is a
being filed.
City of Round Rock
FORM 1295
1 of 1
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016-97284
Date Filed:
08/10/2016
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.
Creek Bend Blvd Extension
Void Closure 4, 5, & 6
4 Nature of interest
Name of Interested Party City, State, Country (place of business
(check applicable)
Controllinct I Interme
15 Check only if there is NO Interested Party.
X
71
6 AFFIDAVIT
I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
NMI TEERLICXAS0.31-2018_
Signature of aup rized agent of �tracting busi ess entity
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said L this the 1_ day of �.
20_��, to certify which, witness my hand and seal office.
Sig
Forms p
of officer administering oath
by Texas Ethics Commission
of officer administering oath
www.etnics.state.tx.us
of officer administering oath
Version V1.0.277
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.277
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 of 1
Complete Nos. 1- 4 and 6 if there are interested parties.
Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.
OFFICE USE ONLY
CERTIFICATION OF FILING
Certificate Number:
2016-97284
Date Filed:
08/10/2016
Date Acknowledged:
08/29/2016
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Capital Excavation
Buda, TX United States
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
City of Round Rock
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.
Creek Bend Blvd Extension
Void Closure 4, 5, & 6
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
5
Check only if there is NO Interested Party.
X
6
AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP / SEAL ABOVE
Sworn to and subscribed before me, by the said this the day of
20 , to certify which, witness my hand and seal of office.
Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.277