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Backup Documents 03/25/2025 Item #16C 1 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 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 he forwarded to the County Attorney Office at the time the item is placed on the agenda. All completed routing slips and original documents must he received in the County Attorney Office no later than Monday preceding the Board meeting. ** ROUTING SLIP** Complete routing lines N 1 through 42 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 41 through 42,complete the checklist,and forward to the County Attorney Office. Route to Addressees)(List in routing order) Office Initials Date I. 2. 3. County Attorney Office County Attorney Office ,7 Wcp-A.)—r 4. BCC Office Board of County Commissioners 5. Minutes and Records Clerk of Court's Office ` 4-'f w- G+(�3‘1.1'l1 9/ 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 Tom Sivert,PUEPMD Phone Number f Z 1" Contact/Department �" Agenda Date Item was 3—� 2o;z-'2 Agenda Item Number ,?` (1 / Approved by the BCC c '-e Type of Document(s) -Ft jl Number of Original - ! Attached (✓�`f` ''" �� (�� '" Documents Attached ` PO number or account number if document is Ar/e4--- 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) I. Does the document require the chairman's original signature(instead of stamp)? le 2. Does the document need to be sent to another agency for additional signatures? If yes, 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 the Chairman,with the exception of most letters,must be reviewed and signed by the Office of the County-Attorney.) 'r' 4. All handwritten strike--through and revisions have been initialed by the County Attorney Office and all other parties except the BCC Chairman and the Clerk to the Board. .A9C5r 5. The Chairman's signature line date has been entered as the date of BCC approval of the eig- 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 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 nullifi aware of your deadlines! 8. The document was approved by the BCC on, 2 fL nd all changes made during ,�. NIA is not; the meeting have been incorporated in the attache« document. The County Attorney 12 an option foci Office has reviewed the changes,if applicable. 3 this line, 9. Initials of attorney verifying that the attached document is the version approved by the i/A is fto( BCC,all changes directed by the BCC have been made,and the document is ready for the 514 n option foil; Chairman's signature. Itis line] I:Forms/County Forms/BCC Forms/Original Documents Routing Slip vws Original 9.03.04;Revised 1.26.05;2.24.05; 11/30/12;4/22/16;9/10/21 '' Procurement Services GO .7(:i" , unty Change Order Form ® Contract Modification ❑ Work Order Modification Contract#: 23-8067 Change#: 1 Purchase Order#: 4500225368 Project#: 70069.23 Contractor/Firm Name: Zabatt Power Systems Contract/Project: Tamiami Well#23 Generator Replacement 1 Project Manager Name: Tom Sivert Division Name: PUEPMD Original Contract/Work Order Amount $ 327,681.91 6/27/2023;16C3 Original BCC Approval Date; Agenda Item# Current BCC Approved Amount .1Last BCC Approval Date; Agenda Item# Current Contract/Work Order Amount $ 327,681.91 SAP Contract Expiration Date (Master) Dollar Amount of this Change $ 0.00 0.00% Total Change from Original Amount Revised Contract/Work Order Total $ 327,681.91 #DIV/0! Change from Current BCC Approved Amount Cumulative Changes $ 0.00 0.00% Change from Current Amount Completion Date, Description of the Task(s)Change,and Rationale for the Change Notice to Proceed I 7/24/2023 Original 5/19/2024 Last Approved 5/19/2024 Revised Date TBA Date ( Completion Date Date (Includes this change) #of Days Added 90 Select Tasks ❑Add new task(s) ❑ Delete task(s) 0 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. Project is currently in suspension,effective 3/13/2024 with 67 days remaining on the contract. 1. This change order provides for a 90-day extension to the substantial completion date to accommodate the manufacture and delivery of the new generator and fuel tank. The contractor shall achieve final completion within 30 calendar days of the substantial completion date. 2. This change was not included in the original contract as it was unknown that the production and delivery schedule of the new equipment would be more than a year. 3. If this change order is not processed,the contractor will not have sufficient time to complete the generator replacement. S iveraom Digitally signed by SivertTom Prepared by: Date:2025.02.20 10:52:05-05'00' Date: (Tom Sivert, PM III Lic. PUEPMD) KLA 2/13/25 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: LJet,((___ C: Date: ,(Z( /Z. andra Sabatier,Zabat oer Systems, nc.) Digitally signed by Tyler C Wainright Accepted by., 7„ yler C Wainr1 t Date: (Tyler Wainwright, Tetra Tech) Date..2025.02.21 1✓22 03 05'00' Bel IoneJoseph DlgltaIly signed by Belioneloseph Approved by: Date:zozs.oz.zao7sB:a9-osoo Date: (Matt McLean, Division Director) Bowden St hanie Digitally signed by BowdenStephanie Approved by:_ p Date:2025.02.24 09:43:15-05'00' Date: _ (Procurement Professional) Revised:01/14/2021 (Divisions who may require additional signatures may include on separate sheet.) PROCUREMENT USE ONLY Admin BCC BCC ES Rpt 565 ATTEST: BOARD OF COUNTY COMMISSIONERS Crystal K ,KirfL,,Clerk of Courts COLLIER COUNTY, FLORIDA & Cos iptrollet '/a s f ,,1 ;Attest as to Chairman s Burt L. Saunders, Chairman Dated: signature only (SEAL)',Ay,�� Appro s to forma leg ity: By: Scott R. Teach Deputy County Attorney Change Order/Amendment Summary COST — TIME CO# AMD# Description Days New Justification Additive(+) Deductive(-) Added Amount Time extension required to allow for 1 Time Extension 90 390 an extended generator and fuel tank production schedule. Revised:01/14/2021 (Divisions who may require additional signatures may include on separate sheet.) PROCUREMENT USE ONLY Admin BC ! BCC ES) AFFIDAVIT REGARDING LABOR AND SERVICES Effective July 1,2024, pursuant to§787.06(13), Florida Statutes, when a contract is executed,renewed, or extended between a nongovernmental entity and a governmental entity, the nongovernmental entity must provide the governmental entity with an affidavit signed by an officer or a representative of the nongovernmental entity under penalty of perjury attesting that the nongovernmental entity does not use coercion for labor or services. Nongovernmental Entity's Name: Zabatt Engine Services,Inc. Address: 4612 Highway Avenue,Jacksonville,FL 32254 Phone Number: 904-384-4505 Authorized Representative's Name: Sandra M.Sabatier Authorized Representative's Title: Secretary Email Address: sales@zabatt.com AFFIDAVIT I, Sandra M.Sabatier (Name of Authorized Representative),as authorized representative attest that Zabatt Engine Services,inc. (Name of Nongovernmental Entity)does not use coercion for labor or services as defined in §787.06, Florida Statutes. Under penalty of perjury, I declare that I have read the foregoing Affidavit and that the facts stated in it are true. C. ,..i-t l..3„: 1/9/2025 V / atUti2esent 'ye) Date STATE OF Florida COUNTY OF Duval Sworn to (or affirmed) and subscribed before me, by means of® physical presence or 0 online notarization this 9th day of January ,2025 by Sandra M.Sabatier (Name of Affiant),who produced his Florida Driver's License as identification. ti /,�; ,�. , ,e, ;.s�:,4•, KIMBERLYANN BROWN otary Public6n)t required when digital) +?',,,' h Notary Public.State of Florida i t..r' ..‹.7..,.. Commission No.HH 623375 12/25/2028 ?ate`' My Comm.Exp.12/25/2028 Commission Expires Personally Known ®OR Produced Identification 0 Type of Identification Produced: ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 6 C 1 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 he fonsarded 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 ill through fi2 as appropriate for additional signatures,dales,and/or information needed. If the document is already complete with the exception of the Chairman's signature,draw a line through routing lines ill through#2,complete the checklist,and forward to the County Attorney Office. Route to Addressee(s)(List in routing order) Office Initials Date i. 2. 3. County Attorney Office County Attorney Office 5 / yi,i)-s- 4. BCC Office Board of County Commissioners Clerk of Court's Office ` �'C 341 Y11 5. Minutes and Records (� ` PRIMARY CONTACT INFORMATION e Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact infonnation is needed in the event one of the addressees above may need to contact staff for additional or missing information. Name of Primary Staff Tom Sivert,PUEPMD Phone Number s .."" 3 4 Contact/Department Agenda Date Item was 31 r�,. — 20�Z_Lj Agenda Item Number ,r (1 ,/ Approved by the BCC i Lc , Type of Document(s) Number of Original - Attached ��`f` ' �'� "` 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. (hritial) Applicable) 1. Does the document require the chairman's original signature(instead of stamp)? 2. Does the document need to be sent to another agency for additional signatures? If yes, 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 the Chairman,with the exception of most letters, mist 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 Office and all other parties except the BCC Chairman and the Clerk to the Board. gliCar-'--- 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 signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip 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 nullifi 0. B aware of your deadlines! 8. The document was approved by the BCC on,3 . ..` nd all changes made during ,�Z6 WIA is not; the meeting have been incorporated in the attache« document. The County Attorney 2 an option fotj Office has reviewed the changes,if applicable. .7 this iinei 9. Initials of attorney verifying that the attached document is the version approved by the / /A is no# BCC,all changes directed by the BCC have been made,and the document is ready for the 51107 n option'fot! Chairman's signature. ,ills i net I:Forts/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 t6Cl .s.. Procurement Services CO Ter County Change Order Form ® Contract Modification ❑ Work Order Modification Contract#: 23-8067 Change#: 1 Purchase Order#: 4500225368 Project#: 70069.23 Contractor/Firm Name: Zabatt Power Systems Contract/Project: Tamiami Well#23 Generator Replacement Project Manager Name: Tom Sivert Division Name: PUEPMD Original Contract/Work Order Amount $ 327,681.91 5/27/2023;16C3 Original BCC Approval Date; Agenda Item# Current BCC Approved Amount Last BCC Approval Date; Agenda Item# Current Contract/Work Order Amount $ 327,681.91 SAP Contract Expiration Date (Master) Dollar Amount of this Change $ 0.00 0.00% Total Change from Original Amount Revised Contract/Work Order Total $ 327,681.91 #DIV/0! Change from Current BCC Approved Amount Cumulative Changes $ 0.00 0.00% Change from Current Amount Completion Date, Description of the Task(s) Change,and Rationale for the Change Notice to Proceed I 7/24/2023 Original 5/19/2024 Last Approved 5/19/2024 Revised Date TBA Date Completion Date Date (Includes this change) #of Days Added 90 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. Project is currently in suspension, effective 3/13/2024 with 67 days remaining on the contract. 1. This change order provides for a 90-day extension to the substantial completion date to accommodate the manufacture and delivery of the new generator and fuel tank. The contractor shall achieve final completion within 30 calendar days of the substantial completion date. 2. This change was not included in the original contract as it was unknown that the production and delivery schedule of the new equipment would be more than a year. 3. If this change order is not processed,the contractor will not have sufficient time to complete the generator replacement. S ivertTom Digitally signed by SivertTom Prepared by: Date:2025.02.20 10:52:05-05'00' Date: (Tom Sivert, PM III Lic. PUEPMD) KLA 2/13/25 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. r Accepted by: j (� C .- , ,, Date: UI Z( )' andra Sabatier,Zabat oer Systems, Inc.)n ,, Digitally signed by Tyler C Wainright Accepted by. _Niter C Wainria 1 Datc:2025.02.21 13:22:03 05'00 Date: (Tyler Wainwright,Te ra Tech) Be l Io neJose p h Digitally signed by BelloneJoseph Approved by: Date:zozsoz.za07s3:a9-osoo Date: (Matt McLean, Division Director) hanie Digitally signed by BowdenStephanie BowdenSte Approved by: p Date:2025.02.24 09:43:15-05'00' Date: (Procurement Professional) Revised:01/14/2021 (Divisions who may require additional signatures may include on separate sheet.) PROCUREMENT USE ONLY Admin RPC BCC Es) 565 (11 ATTEST: BOARD OF COUNTY COMMISSIONERS Crystal K.KirI2 ,Clerk of Courts COLLIER COUNTY, FLORIDA & Comptroller' n "0 By.: 1 • ;1 By: ;'A,ttest as to Ch- i Burt L. Saunders, Chairman Dated: vt4 ! s 0. to' only (SEAL) Appro s to forma leg ity: By: Scott R. Teach Deputy County Attorney Y'j'. Change Order/Amendment Summary 1 6 C 1 , COST TIME CO# AMD# Description Days New Justification Additive (+) Deductive(-) Added Amount Time extension required to allow for 1 Time Extension 90 390 an extended generator and fuel tank production schedule. 1111 IIII Revised:01/14/2021 (Divisions who may require additional signatures may include on separate sheet.) PROCUREMENT USE ONLY Adman RP° [ BCC E 16C1 - AFFIDAVIT REGARDING LABOR AND SERVICES Effective July 1,2024, pursuant to§787.06(13), Florida Statutes, when a contract is executed,renewed, or extended between a nongovernmental entity and a governmental entity, the nongovernmental entity must provide the governmental entity with an affidavit signed by an officer or a representative of the nongovernmental entity under penalty of perjury attesting that the nongovernmental entity does not use coercion for labor or services. Nongovernmental Entity's Name: Zabatt Engine Services,Inc. Address: 4612 Highway Avenue,Jacksonville,FL 32254 Phone Number: 904-384-4505 Authorized Representative's Name: Sandra M.Sabatier -_� Authorized Representative's Title: Secretary Email Address: sales@zabatt.com AFFIDAVIT I, Sandra M.Sabatier (Name of Authorized Representative),as authorized representative attest that Zabatt Engine Services,Inc. (Name of Nongovernmental Entity)does not use coercion for labor or services as defined in §787.06,Florida Statutes. Under penalty of perjury, I declare that I have read the foregoing Affidavit and that the facts stated in it are true. 0 mac— 1/9/2025 Signature of authorized r present •ve) Date STATE OF Florida COUNTY OF Duval Sworn to (or affirmed) and subscribed before me, by means of® physical presence or 0 online notarization this 9th clay of January , 2025 by Sandra M Sabatier (Name of Affiant),who produced his Florida Driver's License as identification. l �// ��`E'`" `� ' • KIMBERLYANN BROWN (Votary Public6nt required when digital) tt Notary Public,State of Florida Commission No.KH 623375 12/25/2028 ''forM14,' My Comm.Exp.12/25/2028 Commission Expires Personally Known ® OR Produced Identification CI Type of Identification Produced: CA()