Backup Documents 10/10/2023 Item #16F 5 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 F 5
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.
**NEW** 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. County Attorney Office County Attorney Office
/0/A
2. BCC Office Board of County
Commissioners Chairman Qt lol�'L3
3. Minutes and Records Clerk of Court's Office 11)61 a) V'
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 Bendisa E. Zela, Facilities Phone Number 239-252-8440
Contact/ Department Division Email Bendisa.Zela@colliercountyfl.gov
Agenda Date Item was October 10,2023 Agenda Item
Approved by the BCC Number I 6.F.5
Type of Document Administrative Change Order No. Number of Original
Attached 1 adding$40,828.35 to Purchase Documents 1
Order No.4500223989 under Attached
Agreement No. 19-7592.
PO number or account Facilities Division is re ting a
number if document is to completed copy
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)
I. Does the document require the chairman's original signature? N/A
2. Does the document need to be sent to another agency for additional signatures? If yes, N/A
provide the Contact Information(Name;Agency;Address; Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman, with the exception of most letters, must be reviewed and signed BEZ
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A
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 BEZ
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
signature and initials are required. /
7. In most cases(some contracts are an exception),the original document and this routing slip N/A
should be provided to the County Attorney Office at the time the item is input into SIRE.
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 July,25 2023 N/A is not
and all changes made during the meeting have been incorporated in the attached an option for
document. The County Attorney's Office has reviewed the changes,if applicable. *fife?
this line.
9. Initials of attorney verifying that the attached document is the version approved by the N/A is not
BCC,all changes directed by the BCC have been made, and the document is ready for the T' an option for
Chairman's signature. 7 � this line.;
1:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
1 6F 5
Procurement Services
Corner ier County Change Order Form
❑ Contract Modification E Work Order Modification
r 4500223989 52162.1
Contract#:' 19-7592 Change#: 01 Purchase Order#: Project#:
Contractor/Firm Name: Juice Technologies, Inc.dba Plug Smart Contract/Project: Bldg L1 Courthouse Annex
Project Manager Name: Tim Rygiel, PMP, Project Manager II Division Name: Facilities Management
Original Contract/Work Order Amount $ 430,237.17 3/14/23 16C1 Original BCC Approval Date; Agenda Item#
Current BCC Approved Amount $ 430,237.177 3/14/23 16C1 Last BCC Approval Date; Agenda Item#
Current Contract/Work Order Amount $ 430,237.17 4/27/2025 SAP Contract Expiration Date (Master)
Dollar Amount of this Change $ 40,828.35 9.49% Total Change from Original Amount
Revised Contract/Work Order Total $ 471,065.52 9.49% Change from Current BCC Approved Amount
Cumulative Changes $ 40.828.35 9.49% Change from Current Amount
Completion Date, Description of the Task(s)Change,and Rationale for the Change 1
Notice to Proceed NA Original NA Last Approved NA Revised Date NA
Date Completion Date Date (Includes this change)
#of Days Added 0 Select Tasks ®Add new task(s) E Delete task(s) ❑Change task(s) ❑Other
Provide a response to the following: 1.)detailed and specific explanation/rationale of the requested change(s)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.
1. This change order will add$40,828.35 to the total project amount due to defective actuators on all of the Air Handler Units
(AHU's),defective outside air dampers, and a defective chilled water valve.
2. This change was not included in the original scope as the defective equipment could not have been discovered until the project
started.
3. If this change order is not processed,a proper Test and Balance of the system included in the project will not be able to be
acquired. The Test an Balance of the system is a crucial component to assure the HVAC and Smoke control systems operate
as designed.
RygielTimothy Digitally signed by RygielTimothy
Prepared by: Date: 2023.08.29 16:29:08 -04'00' Date:
Tim Rygiel-PMP, CFM, Project Manager II, Facilities Management
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.
Thomas M . Martin aa�,:: Date: 8/31/23
Accepted by: 8,1
Thomas Martin-SBS VP Florida,Juice Technologies Inc.
M cC o rm i ckJ o h n Digitally signed by McCormickJohn
Approved by
Date: 2023.08.31 09:29:53 -04'00' Date:
John McCormick, Interim Director, Facilities Management
Zi m m e rm a n S u e Digitally signed by ZimmermanSue
Approved by:
Date: 2023.09.07 15:02:08 -04'00' Date:
(Procurement Professional)
Revised:01/14/2021 (Divisions who may require additional signatures may include on separate sheet.) PROCUREMENT USE ONLY
Admin �iAt/ BCC ES
1
A 1.1'ES I: BOARD OF COUNTY COMMISSIONERS
Crystal K. Kity.e 'le- If Courts COLLIER COUNTY, FLORIDA
f-1/4,4' frell ill
— T ra •
Rick LoCastro, Chan-man
:, / )/1/4, : -:
Dated? 1/4, 1
AL) .: .e,tt,itt to Chairman's
gic,.1/4„i4-1itnature only
Appro as to fon an,w ty:
By:
Sc . Teach
Deputy County Attorney
1 6 1-
Change Order/Amendment Summary
COST TIME
CO# AMD# Description Days New Justification
Additive(+) Deductive(-) Added Amount
If this change order is not
processed, a proper Test and
Balance of the system included in
Adds$40,828.35 the project will not be able to be
1 to the total project $40,828.35 acquired.The Test an Balance of
amount. the system is a crucial component
to assure the HVAC and Smoke
control systems operate as
designed.
Revised:01/14/2021 (Divisions who may require additional signatures may include on separate sheet.) PROCUREMENT USE ONLY
Admin ` tom BCC ES A