Backup Documents 04/22/2025 Item #16F4 ORIGINAL DOCUMENTS CHECKLIST&ROUTING SLIP 6F
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's Office County Attorney Office
If j/
2. BCC Office Board of County Commissioners Chairman
3. Minutes and Records Clerk of Court's Office
p- iZ
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
addresses above,may need to contact staff for additional or missing information.
Name of Primary Staff Bendisa E.Miller,Facilities Division Phone 239-252-8440
Contact/Department Number Bendisa.Miller@colliercountyfl.gov
Email
Agenda Date Item was April 22,2025 Agenda
Approved by the BCC Item 16.F.4
Number
Type of Document Attached Recommendation to ratify administratively approved Number of
Change Order No. I,adding 24 days to the project Original I
time under Agreement No.24-8250,Golden Gate Documents
Golf Course Outfall Swale,constructing Attached
approximately 2,400 linear feet of a 35-foot-wide
lined swale and a 300 linear foot outfall pipe at the
Golden Gate Golf Course,and authorize the Chairman
to sign the attached Change Order.(Project No.
80412)
PO number or account The Facilities Division is requesting a completed copy
number if the 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
(Initial) Applicable)
1. 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,provide the Contact N/A
Information(Name,Agency,Address,Phone)on an attached sheet.
3. The original document has been signed/initialed for legal sufficiency. (All documents to be signed by the
Chairman,except for most letters,must be reviewed and signed by the Office of the County Attorney. BEM
4. All handwritten strikethroughs and revisions have been initialed by the County Attomey's Office and all N/A
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 BEM
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 N/A
provided to the County Attorney's 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 BCC approved the document on April 22,2025,and all changes made during the meeting have N/A is not an
been incorporated in the attached document. The County Attorney's Office has reviewed the M1j option for this
changes,if applicable. line.
9. Initials of attorney verifying that the attached document is the version approved by the BCC,all changes / N/A is not an
directed by the BCC have been made,and the document is ready for the Chairman's signature. option for this
line.
I: 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
16F4
ter Collor y
Procurement Services Change Order Form
Contract# 24-8250 CO#01 PO#4500234938 Project#: 80412,1 �
Project Name: Golden Gate Golf Course Outfall Swale
Contractor/Consultant Name: South Florida Excavation, Inc.
Select One: 1J Contract Modification(Construction or Project Specific) ❑Work Order Modification
Project Manager Name: James Morton Division Name:[Facilities Management
Original Contract/Work Order Amount $1,877,712.00 09/24/2024 16F11 ! Original BCC Approval Date;Agenda Item#
Current BCC Approved Amount $1,877,712.00 09/24/2024 16F11 Last BCC Approval Date;Agenda Item#
Current Contract/Work Order Amount $1,877,712.00 4/9/2025 SAP Contract Expiration Date(MASTER)
Dollar Amount of this Change 0.00% Total%Change from Original Amount
Revised Contract/Work Order Total $1,8n,712.00 0.00% %Change from Current BCC Approved Amount
Total Cumulative Changes S0.00 0.00% %Change from Current Amount
Notice to Proceed[1-2-/-1-072024 Original NTP t20 Original Final 4/9/2025 Last Final 4/19/2025
Date — #of Days Completion Date Approved Date
#of Days Added [24 Revised Final Date Current Substantial Completion Date
3/20/2025
(includes this change)[TBD (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.
This change order will add 24 days to the project to allow the contractor to complete the scope of the
project.
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.
This project is currently under a Stop Work as of 3/19/2025 with 31 days remaining.
3.) Explain why this change was not included in the original contract/Work Order.
The additional time is being provided to support account for the timeline associated with obtaining
South Florida Water Management District (SFWMD) permits for the final phase of the project.
4.) Describe the impact if this change is not processed.
If this change order is not processed, there would be limited time to complete the scope of work and
address the requirements of the SFWMD permit.
Page 1 of 4
Change Order Form(2023_ver.1)
16F4
Colter County
Procurement Services Change Order Form
Contract# 24-8250 Co#01 PO# 4500234938 Project#: 80412.1
Project Name: Golden Gate Golf Course Outfall Swale
Contractor/Consultant Name: South Florida Excavation, 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 j Days Total New Justification
(+) „--Ja Added Time
Adds 24 days to ii� The additional time is being provided to
support account for the timeline
1 the project. 24 i 144 associated with obtaining South Florida
Water Management District(SFWMD)
permits for the final phase of the project.
❑Check here if additional summary page/s are attached to this Change Order
Page 2 of 4
Change Order Form(2023_ver.1)
CA 0
16F4
Lit). c:.c7ursty
�.- •-- ._ Procurement Services Change Order Form
Contract# 24-8250 CO#01 PO# 4500234938 Project#: 80412.1 -- j
Project Name: Golden Gate Golf Course Outfall Swale
Contractor/Consultant Name: South Florida Excavation, 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.nryflorida.conr%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.
MortonJames Digitally signed by MortonJames
Prepared by: Date:2025.03.19 15.35:20.04'00' Date:
Signature 'r•oject Manager
James Morton P.E., Project Manager III, Facilities Management
Printed Name
bra Digitally signed by Jeff Davidson
Accepted by: Date:2025.03.19 15:46 48_04'00' Date:_*
Signature- ;csign/Engineer Profc > ..,r!i'(if applicable)
Jeff Davidson, President. Davidson Engineering, Inc.
Printed Name/Title/Company Name — —
Russell Anderson Digitally signed by Russell Anderson
Accepted by: Date:2025.03.19 17.11:12-04'00' Date: 3/19/2025
Signature-`;ontractor/Cor snh:,'^V"nr'or
Russell Anderson, President, South Florida Excavation, Inc.
Printed Name/Title/Company Name
Approved by: Date: _
Signature-Division Manager or Designee(Optional)
Printed Name
Delon Brian Digitally signed by DelonyBrian
Approved by: Date:2025.03.19 15:21:36.04'00' Date:
Signature-Division Director or Designee(Optional)
Brian DeLony P.E.,Division Director,Facilities Management
Printed Name
Approved by: Date:
_..__........_...
Signature-Division Administrator or Designee(Optional)
Printed Name
Page3of4
Change Order Form(2023_ver.1)
16F4
c; slier County
Procurement Services Change Order Form
Contract# 24-8250 CO# 1 PO# 4500234938 Project Si: 80412.1
Project Name: Golden Gate Golf Course Outfall Swale
Contractor/Consultant Name: South Florida Excavation, Inc.
FOR PROCURMENT USE ONLY
FY 25 CHO Request# 626
B o W d e n Stephanie Digitally signed by BowdenStephanie
Date:2025.03.21 09:26:09-04'00'
Approved by:
Signature-Procurement Professional Signature/Date
Approved by:............. y—
Signature-Procurement Manager/Director(OPTIONAL)
APPROVAL TYPE:
Administrative X Administrative-BCC Report BCC Stand-Alone ES(BCC Approval Required)
BCC APPROVAL
ATTEST:
Crystal K: Kir C.te c the Circuit Court BOARD OF COUNTY COMMISSIONERS
and ComptF
i "e COLLIER COUNTY, FLORIDA
�},�, � `
By: 044#3.,Z1 BY '� __..
Burt L. Saunders
�d► -__, Chairman
Dated:
Attest as to Chalcmans Date: /2 2./2 5
signetare onty.(SEAL) Agenda#...__ 16
A roved as For
fr• -gality:
Deputy County Atttoorney
_._- __._1/ .. L__
Print Name
Page 4 of 4
Change Order Form(2023_ver.1) ( I/)
16F 4
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: ',South Florida Excavation,Inc.
Address: 1455 Railhead Blvd.,Suite 3,Naples,FL 34110
Phone Number: 239-596-8111
Authorized Representative's Name: Russell Anderson
Authorized Representative's Title: President
[Email Address Russell@sflexcavation.com J
AFFIDAVIT
I, Russell Anderson (Name of Authorized Representative), as authorized representative attest
that South Florida Excavation,Inc _(Name of Nongovernmental Entity)does not use coercion for labor or
services as defined in § 787.06, Florida Statutes,
Und, .r na tf}r o rpy.rq;.,l declare that I have read the foregoing Affidavit and that the facts stated in it are true,
2c.
(Signature authorized representative) Date
STATE OF FL..,...__....__....._.___.__
COUNTY OF Collier
Sworn to(or affirmed)and subscribed before me,by means of! physical presence or0 online notarization this
20th day of Mach 20 by Russell Anderson (Name of Affiant),who produced their known
as identification or are personally known to me.
rf/ ;, .- -
Notary Public i) A: NANCYEVANEK _.__
4/22/27 =;`" . :`; MY COMMISSION#Hit39628
EXPIRES:April 22,2027
Commission Expires :.1-- — .. ....,.
Personally Known ?I OR Produced Identification El
Type of Identification Produced: Known _, —
CONTRACT RENEWAL,OR EXTENSION REQUEST FORM Version:2025.1.