Contract - Lone Star Paving - 2/25/2021 Page I of 3
Contract Quantity Adjustment/Change Order
ROINU RACK i!■Ai
rev,01/16
Department: Y� r a
Project
Name: 2019 SMP Project D TY F Overlay Date: 10/28/20
City Project Change Order/Quantity
ID Number Adjustment No. 1
Vendor Lone Star Paving 11675 Jollyville Rd, Suite 150 Austin,TX 78759 512-428-5778
Company Name Address Phone No.
Justification
CORR added TY F Overlay Eagles nest from Hawkview to University which was Line item 1.There was also the addition of full depth repairs at
meadow Lake subdivision which resulted on the increase on line item #2. Line item #3 was increased because we had to do edge milling to
complete the Overlay on added section of Eagles Nest. Line Item #5 was increased due to more manholes being out there than the contract
originally had. The change order is for the work we did for the CORR at Egger Acres. It was full depth repairs plus the extra traffic control
measures we had to take to do our work out there.
SUMMARY Amount %Change
Original Contract Price: $1,032,002 50 `4 �
Previous Quantity Adjustment(s): J:
This Quantity Adjustment: $178,863 55
Total Quantity Adjustment(s): $178 863 55 �
Total Contract Price with Quantity Adjustment(s): $1,210,866 05
Previous Change Order(s):
This Change Order: $0.00 0%
Total Change Order(s)To Date: $0.00 0%
Adjusted Contract Price [Original Contract Price Plus ' �,t,. ���
Quantity Adjustment(s)Plus Change Order(s)]: $1,210,866.05
Difference between Original and Adjusted Contract Prices: $178,863.55
Original Contract Time: 60
Time Adjustment by previous Quan.Adj./Change Order: 32
Time Adjustment by this Quan.Adj./Change Order:
New Contract Time: 92
O
Prepared By:
�yy Ruben Romero, PM, Lone Star Paving 1/29/2021
Signature Printed Name,Title,Company Date
Contractor: / � � Ruben Romero, PM, Lone Star Paving 1/29/2021
Signature Printed Name,Title,Company Date
City Project
Manager: /l Z
ONI IO a� � � zi
nature Printed Name,Tit Ue U Date
Mayor/City
Manager YOB
b-�gr&ure Printed Name,Title Date
�,-211-059
Page 2 of 3
Contract Quantity Adjustment/Change Order
ROUND ROOF tE r '>
rev,01,16
Project Name: 2019 SMP Project D TY F Overlay
Quan. Adj./Change Order No.: 0
Change Order Data
Contract
Time
Adjustment
Item # Item Description Unit Qty. Unit Price Amount (Days)
$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
-A $0.00
TOTALS: $0.00 0
Page 3 of 3
Contract Quantity Adjustment/Change Order
T
Project Name: 2019 SMP Project D TY F Overlay
Quan. Adj./Change Order No.: 1
Quantity Adjustment Data
Contract
Time
Adjustment
Bid Item # Item Description Unit Qty. Unit Price Amount
1 TY F-HMAC 1" Overylay&Tack TON 1195.75 $100.00 $119,575.00 2
2 Pavement Repair TON 1578.03 $110.00 $173,583.30 4
3 Edge Milling - 6'Wide SY 4231 $3.00 $12,693.00 1
4 Vavee Can Adjustment EA -2 $225.00 -$450.00 0
5 Manhole Adjustment EA 32 $275.00 $8,800.00 25
R& R Concrete Curb and Gutter(incl 4"
6 TY A or TY B) LF -639.2 $60.00 -$38,352.00
7 R& R Reinforced Concrete Driveway SF -2853.9 $17.50 -$49,943.25
8 R& R Reinforced Concrete Sidewalk SF -2907 $17.50 -$50,872.50
9 Reinforced Concrete Sidewalk Ramp EA -1 $2,750.00 -$2,750.00
10 R& R Reinforced Concrete Valley Gutter SF -48 $40.00 -$1,920.00
11 Traffic Control MO 1 $8,500.00 $8,500.00
$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: $178,863.551 32
CERTIFICATE OF INTERESTED PARTIES
FORM ZZgJ
1 of 2
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, 2021-714799
Lone Star Paving
Austin,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 02/08/2021
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.
2019 SMP Project D TY F Overla
2019 SMP Project D TY F Overlay
Nature of interest
4
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling intermediary
Morisey, Greg Austin,TX United States X
Knox,Allen Austin,TX United States X
Playfair,Thomas Austin,TX United States X
Ohlendorf, Ryan San Antonio,TX United States X
Ramming,John Austin,TX United States X
Kaitlin Wheeler Heritage Trust, Austin,TX United States X
Nolan Wheeler Heritage Trust, Austin,TX United States X
Patrick Wheeler Heritage Trust, Austin,TX United States X
Preferred Materials Inc, Austin,TX United States X
Asphalt Inc Employee Investments, Austin,TX United States X
Wheeler,John Austin,TX United States X
Spinn, Steve Austin,TX United States X
I Cabaza,Aaron Austin,TX United States X
Lundquist, Dean Austin,TX United States X
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.ceffd98a
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
2 of 2
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. 2021-714799
Lone Star Paving
Austin,TX United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the torn is 02/08/2021
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.
2019 SMP Project D TY F Overla
2019 SMP Project D TY F Overlay
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling I Intermediary
5 Check only if there is NO Interested Party. ❑
6 UNSWORN DECLARATION
My name is C , 13 ro Gt.,''\ and my date of birth is
My address is ( 0 -,, 5+ t'a-0— T "X 1A �jkS
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in 17ra-V r 5 County, State of � on the_ day of F'_ 20 ZA_.
(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.ceffd98a
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 of 2
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. 2021-714799
Lone Star Paving
Austin,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 02/08/2021
being filed.
City of Round Rock Date Acknowledged:
02/22/2021
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.
2019 SMP Project D TY F Overla
2019 SMP Project D TY F Overlay
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
Morisey, Greg Austin, TX United States X
Knox Allen Austin TX United States X
Playfair,Thomas Austin, TX United States X
Ohlendorf, Ryan San Antonio,TX United States X
Ramming,John Austin,TX United States X
Kaitlin Wheeler Heritage Trust, Austin, TX United States X
Nolan Wheeler Heritage Trust, Austin, TX United States X
Patrick Wheeler Heritage Trust, Austin, TX United States X
Preferred Materials Inc, Austin, TX United States X
Asphalt Inc Employee Investments, Austin, TX United States X
Wheeler,John Austin,TX United States X
Spinn, Steve Austin, TX United States X
Cabaza,Aaron Austin,TX United States X
Lundquist, Dean Austin, TX United States X
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.1.ceffd98a
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
2 of 2
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. 2021-714799
Lone Star Paving
Austin,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 02/08/2021
being filed.
City of Round Rock Date Acknowledged:
02/22/2021
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.
2019 SMP Project D TY F Overla
2019 SMP Project D TY F Overlay
Nature of interest
4
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
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.ceffd98a