Backup Documents 03/11/2025 Item #16B 9 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 16 6
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.
2.
3. County Attorney Office County Attorney Office 5/2-1 it/r1/Jras
4. BCC Office Board of County
Commissioners 654 /1J ' `f/Z f ZS
5. Minutes and Records Clerk of Court's Office l cI J4 c 'S3
U a-Wt
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 Michael Tisch/Transportation Engineering Contact Information 239-252-5839
Contact/Department
Agenda Date Item was March 11,2025 Agenda Item Number 2025-394- 16.B.9
Approved by the BCC
Type of Document Change Order No.2,Project 33620, Number of Original 1
Attached Agreement No. 19-7599,Capital Consulting Documents Attached
Solutions,LLC
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 original signature STAMP OK I MPT
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 'MPT
signed by 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'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
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 i MPT
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 3/11/2025 and all changes made during 'MPT N/A is not
the meeting have been incorporated in the attached document. The County an option for
Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the ' MPT N/A is not
BCC,all changes directed by the BCC have been made,and the document is ready for the an option for
Chairman's signature. this line.
1689
Colley County
Procurement Services Change Order Form
Contract# 19-7599 CO#2 PO# 4500210044 Project#: 33620.4
Project Name: 111th Ave. N Paved Shoulders
Contractor/Consultant Name; Capital Consulting Solutions, LLC.
Select One: ❑✓ Contract Modification(Construction or Project Specific) ❑Work Order Modification
Project Manager Name: Michael Tisch Division Name: Transportation Engineering
Original Contract/Work Order Amount $94,130.68 2/23/21;16A.17 Original BCC Approval Date;Agenda Item#
Current BCC Approved Amount $94,130.68 2/23/21;16.A.17 Last BCC Approval Date;Agenda Item#
Current Contract/Work Order Amount $94,130.68 5/1/2025 SAP Contract Expiration Date(MASTER)
Dollar Amount of this Change $o.00 o.00%a Total %Change from Original Amount
Revised Contract/Work Order Total $94,130,68 0.00% %Change from Current BCC Approved Amount
Total Cumulative Changes $o.00 o,00%%o %Change from Current Amount
Notice to Proceed 09/26/23 Original NTP 330 Original Final 8/21/24 Last Final 12/09/24
Date #of Days Completion Date Approved Date
#of Days Added 65 Revised Final Date TBD Current Substantial Completion Date
(includes this change) (if applicable)
Provide responses after each question in box below (Responses should be brief and specific). Attach additional information and/or
documentation from the Design Professional and/or Contractor, if needed, with your submission of this Change Order and complete
summary on next page. Check all that apply to this Change Order request: 0 Add Time; ❑Add funds; ❑Use of Allowance;
❑ Modify/Delete existing Task(s); ❑Add new Task(s); ❑ Reallocate funds; ❑ Other(must be explained in detail below)
1.) This is a zero dollar ($0) change order that seeks to only add time for post-design consulting
services (Task 6) for the construction duration.
2.) A Stop Work Notice was issued on December 6, 2024, and 3 days remain on the contract.
3.) The timing of the construction phase was unknown at the project start.
4.) If this change is not processed the Consultant could not perform the tasks necessary to provide the
professional engineering services required during construction, and complete the necessary
documents to certify the work and close out the project.
Page 1 of 4
Change Order Form(2023_ver.1)
1689
Cot.ticr County
Procurement Services Change Order Form
Contract# 19-7599 CO#2 PO# 4500210044 Project#: 33620.4
Project Name: 111th Ave. N Paved Shoulders
Contractor/Consultant Name: Capital Consulting Solutions, LLC.
Change Order/Amendment Summary
(If additional spaces needed, attached a separate Summary page to this amendment request)
COST TIME
CO# AMD# Description Additive Deductive Days Total New Justification
(+) (-) Added Time
Add 65 days to the Additional time is needed to provide
professional post-design services
2 contract. 65 395 (Task 6)through construction.The
Procurement process took much
longer than anticipated.
❑Check here if additional summary page/s are attached to this Change Order
Page 2 of 4
Change Order Form (2023_ver.1)
1659
Code ' County
Procurement Services Change Order Form
Contract# 19-7599 CO#2 PO# 4500210044 Project#: 33620.4
Project Name: 111th Ave. N Paved Shoulders
Contractor/Consultant Name: Capital Consulting Solutions, LLC.
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.
Contractor/Consultant/Design Professional signature below must be from an authorized person/officer/director of
the Company or listed as the qualified licensed Professional"Project Coordinator"or Design/Engineer Professional
under the agreement. Signature authority of person signing will be verified through the contract OR through the
Florida Department of State, Division of Corporations (Sunbiz) website (https://dos.mvflorida.com%sunbiz/search/).
If the person signing is not listed, we will require signature authority by one of the listed officers/directors of the
company giving that person signature authority.
TischM ichael Digitally signed by TlschMichael
Prepared by: Date:2024.12.09 13:50:14-05'00' _ Date:
Signature-Division Project Manager
Michael Tisch
Printed Name
Accepted by: Date:
Signature-Design/Engineer Professional(if applicable)
Printed Name/Title/Company Name
Adam Ahmad Digitally signed by Adam Ahmad
Accepted by: Date:2024.12.10 10:11:40-05'00' Date:
Signature-Contractor/Consultant/Vendor
Adam Ahmad, Managing Member, Capital Consulting Solutions, LLC
Printed Name/Title/Company Name
Approved by: Date:
Signature-Division Manager or Designee(Optional)
Printed Name
AnthonyKhawajaP.E Digitally signed by Anthony Khawaja P.E.
Approved by: Y Date:2024.12.09 14:39:50-05'00' Date:
Signature-Division Director or Designee(Optional)
Anthony Khawaja
Printed Name
ScottTri n ity Digitally signed by ScottTrinity
Date: 2024.12.19 09:38:16-05'00'
Approved by: Date:
Signature-Division Administrator or Designee (Optional)
Trinity Scott
Printed Name
Page 3 of 4
Change Order Form(2023_ver.1)
168q
Co.bier County
Procurement Services Change Order Form
Contract# 19-7599 CO#2 PO# 4500210044 Project#: 33620.4
Project Name: 111th Ave. N Paved Shoulders
Contractor/Consultant Name: Capital Consulting Solutions, LLC.
FOR PROCURMENT USE ONLY
FY 2� CHO Request# 532
Zimmerman B Dlgltally signed by
ZlmmermenBecca
Date.2024.12.20
ecca
Approved by: 1a;aa:o8-osoo
Signature-Procurement Professional Signature/Date
Approved by:
Signature-Procurement Manager/Director(OPTIONAL)
APPROVAL TYPE:
❑ Administrative • Administrative-BCC Report El BCC Stand-Alone ES (BCC Approval Required)
BCC APPROVAL
ATTEST:
Crystal K. Kinzel, Clerk of the Circuit Court BOARD OF COUNTY COMMISSIONERS
and Comptroller COLLIER COUNTY, FLORIDA
: A jeutt.„0.,
By: n 1 By: /44.1l�t�i)100.'"
Attest .hm
/r signatureastoC onlyar an's
Dat,,eho=r``-t' � Burt L. Saunders, Chairman
r _ SE` L) Agenda # 1011 3////z5
L f xi,� i
Ap ed as to pnd L gality:
# .
Deputy County Attorney
S-e—rs (2 --):Eat 4 1_,
Print Name"
Page 4 of 4 C°514:)"
Change Order Form(2023_ver.1)
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