Contract - Murphy Pipelines - 2/11/2016rev, 06/15
Department:
Project
Name:
City Project
ID Number
justification
Contract Quantity Adjustment/Change Order
Utilities & Environmental Services
AC Waterline Repalcement Project - Phase 4
PO No. 3052
Page I of 3
Date: 12/18/15
Change Order/Quantity
Adjustment No. 1
:hange Order - The contractor encoutered existing water main pipelines at non typical depths which required: investigation, extensions for fire
iydrants, haul off of additional fill material, and increases in equipment and labor to perfrom the work. Quanity Adjustment - the contractor has
:ompleted the pipeline activities. Pay Items No. 1 through Pay Items No. 18 are completed and the quantity adjustments are final for said pay
tems.
SUMMARY
Original Contract Price:
Previous Quantity Adjustment(s):
This Quantity Adjustment:
Total Quantity Adjustment(s):
Total Contract Price with Quantity Adjustment(s):
Previous Change Order(s):
This Change Order:
Total Change Order(s) To Date:
Adjusted Contract Price [Original Contract Price Plus
Quantity Adjustment(s) Plus Change Order(s)]:
Difference between Original and Adjusted Contract Prices:
Original Contract Time:
Time Adjustment by previous Quan. Adj./Change Order:
Time Adjustment by this Quan. Adj./Change Order:
New Contract Time:
0
Amount % Change
$1,029,525.00
$0.00
$0.00
$1,029,525.00
0.00
$221,288.47 -0r219.i',,o
$221,288.47 !0 21 to
$1,250,813.47
$221,288.47
Submitted for Approval
l
Prepared By: .C( !lis o� '!IA e A,Nn 7 !,,
Signature Printed Name, Title, &mpany Date
Approvals y
Contractor: i /�'_ �® /4FSaDEwT A -T /,(,4
�Signdt� / Printed Name, Title, Company Date
City Project
Manager:
#�}re Printed Name, Title Date
Mayor/City ign
Manager OV �G�( �VV
Signature Printed Name, Title Date
Contract Quantity Adjustment/Change Order
�( ROUND ROO( I:: `<
rev,/06/15
Project Name: AC Waterline Repalcement Project - Phase 4
Quan. Adj./Change Order No.
Champ nrdPr nata
Page 2 of 3
Item # Item Description Unit
Qty.
Unit Price
Amount
Contract
Time
Adjustment
I !Days
I
Laurel Ridge - WM Investigation /
1 Potholing LS
1
$7,273.13
$7,273.13
Terra Drive - WM Investigation /
2 Potholing LS
1
$3,618.42
$3,618.42
Fire Hydrant Extensions due to Non
3 Typical Existing WM Depths LS
1
$16,392.92
$16,392.92
Depth of Existing WM's Impacts to the
4 Work LF
8176
$22.75
$186,004.00
Haul Off and Dispose of Soils Due to Non
5 Typical Existing WM Depth LD
200
$40.00
$8,000.00
$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
i
TOTALS:
Page 3 of 3
q 'z Contract Quantity Adjustment/ Change Order
�� aouHn wo�c i cz:
rev, 06/15
Project Name: AC Waterline Repalcement Project - Phase 4
Quan. Adj./Change Order No.:
Ouantity AdiuctmPnt nota
CCTALS:1 $0.001 —0
Bid Item # Item Description
Unit
Qty.
UPrice
Amount
Contract
Time
Adjustmentnit
$0.00
$0.00
$0.00
$0.001
$0.00
I $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
CCTALS:1 $0.001 —0
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 of 1
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
Certificate Number:
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
2016-5702
Murphy Pipeline Contractors, Inc.
Jacksonville, FL United States
Date Filed:
01/26/2016
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
Utilities and Enviromental Services Department - Round Rock, TX.
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 goods or services to be provided under the contract.
000000
AC Waterline Replacement Phase 4 Project
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest (check applicable)
Controlling
Intermediary
Jim, Blasczyk
Houston, TX United States
X
Andy, Mayer
Jacksonville, FL 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.
ti� °i''• DAPHNE CANCELLARE
Commission # EE 873754
Expires February 11, 2017
% Bonded Thru Troy Fain Insurance S00J8S-7019
; o� M1,°•:••
Signature of authorized agent of contracting business entity
AFFIX NOTARY STAMP / SEAL ABOVE
I,�,, . -
Sworn to and subscribed before me, by the said this the 3 day ofve Wl
20J to certify which, witness my hand and seal f office.
47
gnature 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 V1.0.34416
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 of 1
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
Certificate Number:
1 Name of business entity filing form, and the city, state and country of the business entity's place
of business.
2016-5702
Murphy Pipeline Contractors, Inc.
Jacksonville, FL United States
Date Filed:
01/26/2016
2 Name of governmental entity or state agency that is a party to the contract for which the form is
being filed.
Utilities and Enviromental Services Department - Round Rock, TX.
Date Acknowledged:
02/03/2016
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 goods or services to be provided under the contract.
000000
AC Waterline Replacement Phase 4 Project
4
Name of Interested Party
City, State, Country (place of business)
Nature of interest (check applicable)
Controlling
Intermediary
Jim, Blasczyk
Houston, TX United States
X
Andy, Mayer
Jacksonville, FL 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.
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 orovided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.34416