Backup Documents 04/22/2025 Item #16C1 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16 C 1
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 Alp and original decunients 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 be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**
Complete routing lines#1 through#2 as appropriate for additional* Usignaatures,ddates,OUNG SLIP
and/orT information needed. If the document is already complete with the
exce Lion of the Chairman's si ature,draw a line throu h routin lines#1 throu h#2 corn lete the checklist,and forward to the Coun Attome Office.
Route to Addressees (List in routing order) Office
1. Initials Date
2.
3. County Attorney Office
County Attorney Office
4. BCC Office 5 --7 a- t9`--
Board of County
Commissioners LZ 5. Minutes and Records Clerk of Court's Office
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 Phone Number
Contact/ Department E„ „t„� cc,,\j AV,b c, 1�;
Agenda Date Item was �J�� rr�,t`1l y�l`��` Zit—�`at 1"it(
Approved by the BCC 4-1 2-- C L�� ‘../ ' Agenda Item Number
Type of Document �' CCI' it C
Attached .t C �� ' Number of Original
PO number or account Documents Attached
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column, whichever is
appropriate. Yes N/A(Not
1. Does the document require the chairman's original signature? (Initial) Applicable)
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 legal sufficiency. (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.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's
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
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 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 ((/zZ and all changes made durin
the meeting have been incorporated in the attached document. The County g P n option
Attorney's Office has reviewed the changes,if applicable, -fi for
s I
9. Initials of attorney verifying that the attached document is the version approved by the N/ i n
BCC,all changes directed by the BCC have been made,and the document is ready for the -�J) A not
Chairman's signature. Sl�I�7 an option for
this line.'
1:Fomrs/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
561
Collier County
Procurement Services Change Order Form
Contract# 23-8112 CO# 2 PO# 4500227917 Project#: 72009.10.4
Project Name: Western Interconnect Phase 7
Contractor/Consultant Name: Accurate Drilling Systems, Inc.
Select One: ❑✓ Contract Modification(Construction or Project Specific) ❑Work Order Modification
Project Manager Name: Zamira Deltoro Division Name: Public Utilities Engineering and Project Management
Original Contract/Work Order Amount $1,983,346.20 9-12-2023;16C1 Original BCC Approval Date;Agenda Item#
Current BCC Approved Amount Last BCC Approval Date;Agenda Item#
Current Contract/Work Order Amount $1,983,346.20 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 $1,983,346.20 0.00% % Change from Current BCC Approved Amount
Total Cumulative Changes $o.00 o.00 %Change from Current Amount
Notice to Proceed 11-1-2023 Original NTP 360 Original Final 10-26-2024 Last Final TBD
Date #of Days Completion Date Approved Date
#of Days Added 97 Revised Final Date TBD Current Substantial Completion Date TBD
(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: 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.) Detail of change/s to be made through this Change Order.
The purpose of this Change Order is to authorize a 97-day extension to the project timeline, allowing
the contractor to reinstall sections of the forcemain pipe located outside the right-of-way, at no
additional cost to the County.
2.) If this Change Order is currently under a Stop Work, please identify the date issued and number of
days remaining or "N/A" if not applicable.
A stop work letter was issued on October 5, 2024, with a total of 34 days remaining.
3.) Explain why this change was not included in the original contract/Work Order.
The project pipeline corridor was surveyed prior to installation. However, a subsequent survey
conducted after the pipeline installation, when plotted against the project design plans, revealed that
two sections of the pipeline are located outside the right-of-way corridor.
4.) Describe the impact if this change is not processed.
Sections of the existing pipeline encroach on private property, and acquiring additional easements is
currently not feasible. This could jeopardize the pipeline's operation once Phase 9 is completed in the
future.
Page 1 of 4
Change Order Form(2023_ver.1)
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CO TCounty 16C1
Procurement Services Change Order Form
Contract# 23-8112 co# 2 PO# 4500227917 Project#: 72009.10.4
Project Name: Western Interconnect Phase 7
Contractor/Consultant Name: Accurate Drilling Systems, Inc.
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
Withdraw from To withdraw from allowances for a
1
Allowances total amount of$10,371.00.
0 0 Remaining allowances=
$109,629.00 ($120,000-
$10,371.00).
Add Time To add time allowing the contractor
to reinstall sections of the
2 97 457 forcemain pipe located outside the
right-of-way. (360+97=457 days)
❑ Check here if additional summary page/s are attached to this Change Order
Page 2 of 4
Change Order Form(2023_ver.1)
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Colter County
Procurement Services Change Order Form
Contract# 23-8112 CO# 2 PO# 4500227917 Project#: 72009.10.4
Project Name: Western Interconnect Phase 7
Contractor/Consultant Name: Accurate Drilling Systems, Inc.
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.
DeltoroZamira Digitally signed by DeltoroZamira
Prepared by: Date:2025.02.05 15:38:17-05'00' Date:
Signature-Division Project Manager
Zamira Deltoro KLA 2/5/25
Printed Name
ft«�-,leam a Der.
Accepted by: ' , � 90.980=502aa131515-0500. Date: 02/06/2025
Signature-Design/Engineer Professional (if applicable)
Lee Davidson, PE/EOR/Davidson Engineering, Inc.
Printed Name/Title/Company Name
Ser io Flores Digitally signed by Sergio Flores
Accepted by: g Date:2025.02.10 21:36:02-05'00' Date:
Signature-Contractor/ConsultantNendor
Sergio Flores/Project Manager/Accurate Drilling System
Printed Name/Title/Company Name
FandrichShon
Approved by: DateGUe 4nnm9B137 9500 e.,Mos,m,., Date:
Signature-Division Manager or Designee(Optional)
Shon Fandrich, PE
Printed Name
Digitally signed by McLeanMallhew
DN:E=Mauhew M goy,
CN nMavhew,M cLea n Matthew OUGeneral,OU=PPM User Accounts, U=UD Planning and Project
Management,OU=PUD,OU=Divisions,DC=bcc,DC=colliergov,DC=net
Approved by: Date 2025.02.1113'.50'.36.05'00' Date:
Signature-Division Director or Designee(Optional)
Matthew McLean, PE
Printed Name
Approved by: Date:
Signature-Division Administrator or Designee (Optional)
Printed Name
Page 3 of 4
Change Order Form(2023_ver.1)
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1 6 C 1
(Altar County
Procurement Services Change Order Form
Contract# 23-8112 CO# 2 PO# 4500227917 Project#: 72009.10.4
Project Name: Western Interconnect Phase 7
Contractor/Consultant Name: Accurate Drilling Systems, Inc.
FOR PROCURMENT USE ONLY
FY 25 CHO Request# 585
Bowd e n Ste p h a n i e Date:Digitally 2025.02.19 signed by14:43:47 Bowden5tep05'00'hanie
Approved by: l
Signature-Procurement Professional Signature/Date
Approved by:
Signature-Procurement Manager/Director(OPTIONAL)
APPROVAL TYPE:
❑ Administrative ❑ Administrative-BCC Report ® BCC Stand-Alone ES (BCC Approval Required)
BCC APPROVAL
ATTEST:
Crystal K. Kinzel; ' kof the Circuit Court BOARD OF COUNTY COMMISSIONERS
and Comptlj•oQe)-� ' COLLIER COUNTY, FLORIDA
By: ��e ;? ;0 ,.. By. it s
"� `
�110 Burt L. Saunders , Chairman
Dated: Ei qa __,S
'''' 'Ma-sta'toChafrmafl Date: 9(22125
sspnaturn only.
(SEAL) Agenda# I K. C.
Ap oved as to Fp nd L galityL,
D t County Attorney
i.6* )2 Q... t
Print Name
Page 4 of 4 �•
Change Order Form(2023_ver.1) rr
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16Ci
From:Sergio Flores<sergio@accuratedrilling.com>
Sent:Wednesday, February 19,2025 1:34 PM
To:Zamira Deltoro<Zamira.Deltoro@colliercountyfl.gov>
Cc: Ismael Irigoyen <ismael@accuratedrilling.com>; Mario E.Acevedo<ace@accuratedrilling.com>
Subject: Re: Western Interconnect-Schedule
EXTERNAL EMAIL: This email is from an external source. Confirm this is a trusted sender
and use extreme caution when opening attachments or clicking links.
Good Afternoon Zamira,
Please see the attached revised Schedule showing the 97 days needed for ADS to perform
the Relocation of Pipe Outside of the ROW.
Thank you.
Sergio Flores
P.O.Box 3035
LaBelle Florida 33975
Office:863.674.0803 Fax:863.674.0912
ADS
kixtuaite Drillintt S)4iemv,Inc.
PRIVILEGED COMMUNICATION.This e-mail,and any attachments thereto,is intended only for the use of the addressee(s)named herein
and may contain legally privileged and/or confidential information.If you are not the intended recipient of this e-mail,you are hereby
notified that any dissemination,distribution or copying of this e-mail,and any attachments thereto,is strictly prohibited.If you have
received this e-mail in error,please notify me via return e-mail and by telephone and permanently delete the original e-mail and any
printout thereof.PRIVILEGED COMMUNICATION.
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16C1
Western Interconnect Forcemain Phase 7
Relocation of 24'.FM Pipe Week 1 Week 2 week 3 week 4 Week 5
Description Station SIVITWT ESSIIIIWTF S S M T W T F S S M T W I F. S S M I W T F S
1 Removal24"HOPE Pipe 27M0ta 36.50 X X % X X X X X X X
2 Reimtallation 24"HOPE Pipe 27.60 to 36.50 X % X X X % X % X X
3 Density Test of backfilled Son27.W to 36+50 % 0 X X % X % X
4 Removal 24-HOPE Pipe 54450 to S9+W
5 Reinstallation 24`HOPE Pipe 54450 to59+W X X X X X X X
6 Density Test of Packfilled Soil 54+50 to 59400 X % X
Week 6 Week 7 Week 4 Week 9 Week 10
Description Station 5 M T W T F S S M T W T P S S M T W T F S S M T WI F 5 SIN T W T F S
7 Collect Asbuilts NA X % % % % X %
S Irrigation Repairs NA X % X X X X X
9 landscaping Details NA % X X X % X X
10 Grading and Cleanup NA X H X X X X X
11 Sod Installation NA X X X % X X %
Week 11 Week 12 Week 13 Week 14
Description Station SIDITWIF 5 S M T W T F S S M T W T F S S M T W T F S
7 ROW Walkthrough NA X %
S Address Ponchlistltems NA X X % % % X % X % % X X
9 ROW Inspection NA X X X %
10 Close out ROW Permit NA X % X % X % X % %
CA°
16
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: Accurate Drilling Systems,Inc
Address: 49 N Industrial Loop,LaBelle,Florida 33975
Phone Number: 239-703-5005
Authorized Representative's Name: Mario Acevedo
Authorized Representative's Title: Project Manager
Email Address: ace@accuratedrilling.com
AFFIDAVIT
I, (Y\Cl(t O i( c-e v'ci (Name of Authorized Representative),as authorized representative attest
that Accurate Drilling Systems,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.
2.. °Iy1Z0-7-5
(Signature o authorized representative) Date
STATE OF Florida
COUNTY OF Hendry
Sworn to (or affirmed)and subscribed before me, by means of LI physical presence or 0 online notarization this
14th day of Feb , 2025 by Mario Acevedo (Name of Affiant),who produced his Florida Driver's License
as identification.
Elvis Torres
Notary Public(not required when digital)
April 17th 2026 1pY A(/pLc ELVIS TORRES
Commission Expires
* .,ter * Commission#HH 25350E
2026
Personally Known II OR Produced Identification 0 4'0F` o�`° Expires ri11Y,
Type of Identification Produced: driver's license
•
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