CM-2016-1222 - 10/31/2016fm«,NORo«T Contract Quantity Adjustment/ Change Order
rev. 1/10
Department: Transportation Administration
Project Traffic Signal - AVERY NELSON BLVD/CR 112 AND
Name: AW GRIMES
City Project
ID Number: TRFSG-600-CON-AVGRM
]ustification
48 in DRILL SHAFT FOR TRAFFIC SIGNAL - NOT ON ORIGINAL PLANS
SUMMARY
Original Contract Price:
Total Contract Price with Quantity Adjustment(s):
Previous Change Order(s):
This Change Order:
Total Change Order(s) To Date:
Previous Quantity Adjustment(s):
This Quantity Adjustment:
Total Quantity Adjustment(s):
Original Contract Price Plus Change Order(s) Plus
Quantity Adjustment(s):
Original Contract Time:
Contract Time Prior to this Change Order:
Contract Time with All Approved Change Orders:
Page 1 of 3
Date: 10/13/2016
Change Order/Quantity Adjustment
No. 1
Signatures and Approvals
Collette Phillips, Asst Controller Austin Traffic
Printed Name, Title and Company
Approva . " .( Ed Schroeder, Vice -Pi
Signature Printed Name, Title and Coml
City Staffn /
Approval: �! Y., ' I ,�I�� ("--) K
- Signature % Printed Name and Title
City Official n , , „ /--v/ ; ; i - . % ,
Printed Name
Austin Traffic Si(
Amount % Change
$237,761.00
$237,761.00
$0.00 0.000/0
$13,223.32 5.56%
$13,223.32 5.56%
$0.00
$0.00
$0.00
$250,984.32
N/A
N/A
N/A
16
Date
I 10/
Date
I0 - /6 -/J�
Date
v'3I-lam
Date
Page 2 of 3
1-t."'ZWR Contract Quantity Adjustment/ Change Order
rev. of/10
Chanae Order Data
Bid Item#
Item Description and Change
Unit
Qty. Unit Price Amount
Contract Time
Adjustment
(Days)
9001-0416
48 IN DRILL SHAFT - TRAFFIC SIGNAL
LF
22 $601.06 $13,223.32
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
0 $0.00 $0.00
TOTALS: $13,223.32
0
Page 3 of 3
1--r6on---mlon
Contract Quantity Adjustment/ Change Order
rev. 01/10
Quantity Adiustment Data
TOTALS: $0.00
Bid Item#
Item Description and Change
Unit
Qty. Unit Price
Amount
Contract Time
Adjustment
(Days)
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
o $0.00
$0.00
0 $0.00
$0.00
o $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
0 $0.00
$0.00
o $0.00
$0.00
o $0.00 1
$0.00
0 $0.00
$0.00
TOTALS: $0.00
CERTIFICATE OF INTERESTED PARTIES FORM 1295
101`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
ERTIFICATION OF FILING
rtificate Number:
[2016-119520
Date Filed:
' 1010412016
Date Acknowledged:
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
Austin Traffic Signal Const. Co, Inc.
Pflugerville, 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.
Avery Nelson/CR112 @ AW Grimes
Traffic Signal Installation - Change Order
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest
(check applicable)
Controlling
I Intermediary
Shin, Fred
Pflugerville, TX United States
X
5 Check only if there is NO Interested Party. ❑
6 AFFIDAVIT I swear, or affirm, under penalty of perjury, that the above disclosure is true and correct.
Collette- Ptate o
Notary Public, 5tatt of 7�zasMy Commission Erpim January 12, 2620
J(9Notary ID# 836259-5 Signature of authorized agent of contracting business en .ry
AFFIX NOTARY STAMP / SEAL ABOVE f
Sworn to and subscribed before me, by the said C= c�� �C,�ti ��-ey— 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 Tide of officrer administering oath
Forms provided by Texas Ethics Commission www, ethics. state, tx.us Version V1.0.2 fl