Backup Documents 01/24/2023 Item #16C 2 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 C 2
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
** ROUTING SLIP**
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing_lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2. (Enter your Dept here)
3. County Attorney Office County Attorney Office
512" 2)49-3
4. BCC Office Board of County
Commissioners RL � M/SJ ?l2 fZ 3
5. Minutes and Records Clerk of Court's Office
IMF= d---33
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above may need to contact staff for additional or missing information.
Name of Primary Staff Madison Bird Phone Number 239-252-2939
Contact/Department
Agenda Date Item was 1/24/23 Agenda Item Number 16.C.2
Approved by the BCC
Type of Document(s) Change Order#2 Number of Original 1
Attached Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's signature?(stamped unless otherwise stated) MB
2. Does the document need to be sent to another agency for additional signatures? If yes, MB
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legality. (All documents to be signed by MB
the Chairman,with the exception of most letters,must be reviewed and signed by the
Office of the County Attorney.)
4. All handwritten strike-through and revisions have been initialed by the County Attorney MB
Office and all other parties except the BCC Chairman and the Clerk to the Board.
5. The Chairman's signature line date has been entered as the date of BCC approval of the MB
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's MB
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip MB
should be provided to the County Attorney Office at the time the item is uploaded to the
agenda. Some documents are time sensitive and require forwarding to Tallahassee within a
certain time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on_1/24/23_and all changes made
during the meeting have been incorporated in the attached document. The County
Attorney Office has reviewed the changes,if applicable. ___________,5e
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made,and the document is ready for the
Chairman's signature.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04;Revised 1.26.05;2.24.05;11/30/12;4/22/16;9/10/21
16C2
DocuSign Envelope ID:005AC8OB-624B-402F-8054-207CA8C614C0
Procurement Services
Cott'County Change Order Form
®Contract Modification 0 Work Order Modification
Contract II: 21-7912 Change II: 2 Purchase Order II: 4500215511 Project N: 71068.32.2
Contractor/Firm Name:HT,inc. jcontracuroiect: NCRWTP Chemical Bulk Tank Replacement
Project Manager Name: Tom Sivert Division Name: PUEPMD
Original Contract/Work Order Amount $ 519,556.00 10/26/21;16C7 Original BCC Approval Date;Agenda Item#j
Current BCC Approved Amount $ 519,568.00I 1/29/2023;16C2 !Last BCC Approval Date;Agenda Item# j
Current Coniract/Work Order Amount $ 519,556.00 1/29/2023 !SAP Contract Expiration Date(Master) j
Dollar Amount of this Change $ 0.00 0,00% !Total Change from Original Amount j
Revised Contract/Work Order Total $ 519,556.00 0.00% ;Change from Current BCC Approved Amount
Cumulative Changes $ 0.00 0.00% ;Change from Current Amount i I
Completion Date,Description of the Task(s)Change,and Rationale for the Change }
Notice to Proceed 12/3/2021 Original 12/3/2022 Last Approved 1/29/2622 Revised Date TBD
Date Completion Date Date 'tPQ, (Includes this change)
II •
of Days Added 84 Select Tasks D Add new task(s) 0 Delete task(s) 0 Change task(s) ®Other
Provide a response to the following:1.)detailed and specific explanation/rationale of the requested change(e)to the task(s)and/or
the additional days added(if requested);2.)why this change was not included In the original contract;and,3.) describe the Impact
if this change Is not processed. Attach additional information from the Design Professional and/or Contractor if needed.
Project Is currently in suspension,effective 12/30/2022.
(t)This change order requests a contract time extension of 84 days necessary to complete the project.The contractors ability to complete '
the scope of work by the current substantial completion date has been Impacted by a delay in the manufacture and delivery of critical
equipment necessary to complete the project. The resulting substantial completion and final completion dates will be established when
the contract Is reactivated.
(2)This change was not included in the original contract as It was not known at that lime of supply chain Issues that would negatively
impact the contractor's ability to meet the schedule.
(3)If the time extension is not processed,the contractor will not be able to complete the project on schedule and would be liable for
liquidated damages for no fault of their own,
Digitally signed by SlvertTom
S i ve rtTo m Date:2023.01.0310:33:17
-05 00
Prepared by: Date:
(Tom Shred,PUEPMD)
Acceptance of this Change Order shall constitute a modification to contract/work order Identified above and will be subject to all the same
terms and conditions as contained In the contract/work order Indicated above,as fully as If the same were stated In this acceptance.The
adjustment,If any,to the Contract shall constitute a full and final settlement of any and all claims of the Contractor/Vendor/Consultant/
Design Professional arising out of or related to the change set forth herein,including claims for Impact and delay costs.
Accepted by: /� Fc� 't' Date: 1 4 2023
•
(Geor.>Agy, {vs rine)—Bohorquez, od p'3,:;'".:�w:"."'"
Accepted by: .P 'E�2_- " ' Francisco dY :«p a ra-- Date: 1/4/2023
(AE OM, Inc.,If project applicable)
Approved by
McLeanMatthow .�� « �»�-: � �K- Date:
(Malt r liti •t*fiislon Director or Designee)
Approved by: ��uu,,�G Date: 1/10/2023
(Weeurtrmen0Prefessional) sue zimmerm ).ocurement contract Manager
Revised:01/14/2021 (Divisions who may require additional signatures may Include on separate sheet.) PROCUMNENT USG ONLY
A-:,: / 01042022 name, a BCC ES
I6C2
ATTEST: BOARD OF COUNTY COMMISSIONERS
Crystal K.Kinzel,Clerk of Courts COLLIER COUNTY, FLORIDA
&Comptroller
•
By: , By:
Rick LoCastro, Chairman
Dated: ?-3
(SEALJ ,
Attest as to Chairman's
signature only.
Approved s fo le ality:
By:
Scott R. T ach
Deputy County Attorney
5
16C2 .
DecoSign Envelope ID:005AC808-624B-4D2F-8054-207CA8C614C0
Change Order/Amendment Summary
COST TIME
CO# AMD# Description — Days New Justification
Additive(+) Deductive(-) _Added Amount
1 Time Extension 67 422 Time extension due to supply chain
Impacts to material delivery.
•
2 Time Extension 84 506 Time extension due to supply chain
Impacts to material delivery.
/al(,c) 01042022
Revised:01/14/2021 (Divisions who may require additional signatures may Include on separate sheel.) PROCUREMENT USE ONLY
AdmIn Rp1 BCC ES