HomeMy WebLinkAboutContract 43373-CO1 TEXAS DEPARTMENT OF TRANSPORTATION
CITY CHANGE ORDER NUMBER: 1
Third Party Funding Notification Sheet CITY SECRETARY
CONTRACT NO., 43373-COI
This form is used when the subject change order involves funding by a source other than TxDOT/U.S.DOT,and involves third
parties who are providing funding under an Advance Funding Agreement or Donation Agreement.
1. Outside funding provided by:
CCSJ: 0902-48-722
City of Fort Worth
(Outside Entity's Legal Name) Project: STP 2012(777)MM
2.Type of outside funding agreement for this change: Highway, CS
EJ Existing ❑ Amended ❑ New County. Tarrant
[Check one j
District: 02-Fort Worth
3. Indicate the type and amount of funding:
Contract
❑Fixed Price(Lump Sum) (Estimated Amount ) Number: 11163008
n Actual Cost
(a) Contract Items(Bid Items): $8,079.96 Use as needed:
I hereby acknowledge notification of the modifications
(b) E&C*: (a)x = $0.00 covered by this Change Order.
(c) Indirect Cost**: (a+b)x = $0.00
enter% Date 6113/17
TOTAL $8,079.96
By
CITY OF FORT WORTH
APPIR9VAL,RECOMMENDED: Typed/Printed Name Jay Chapa
L✓ Typed/Printed Title Assistant Citi. d er•••••..
Dougl W.Wiersig,P.E. -
Director,Transportation/Publi Works Department
The percentage(/°)for E&C(Engineering and Contingencies)charges varies from project to project
depending on the contract amount of the project.Projects with higher contract amount will have the lower rate v_*•:, ,
f
of E"Estimated Cost" the+fect,E&C rate /° can be derived from the cost of"En ineenn and Contin encies in
=�
charge. P p l (° ) 9 9 9 ��
the" project.
**Use the statewide district rate as established by Finance Division each year. This line 3(c)is for Service Project only,
unless otherwise specified in the Advance Funding Agreement. See Stand Alone Manual Notice 98-2 for instructions. t
0 Funding for this Change Order has been arranged:
A3i4 xDOT Representative Date
Typed/Printed Name:TXDOT Form 2146-AFA(Rev.09/2010)Page 1 of 1 Contract Compliance Manager:
By signing I acknowledge that I am the person responsible
PROVED AS TO FORM AND LEGALITY for the monitoring and administration of this contract,including
D6?9-> ensuring all performance and reporting requirements.
Douglas W.Black AA�-
OFFICIAL FdEC� �
Assistant City Attorney Michael Weiss
CITY SECRETARY
Sr.Professional Engineer FT. WORTH,TX
Title
E E
In
k / -0¢ S ¢ p00 a Q
) tmZ
k } LL0
Nui
❑��❑
$
§ (D ®
« \ k § U)
n ; / 0 } < < E
e «
/ 3 \ \ / / E § \
LEN❑El1:1❑ ) ƒ § q
k
ou \
z \ §
§ k 2 0 7
~ � \ ® §
§ \ 2
F-
\ W \
{
ƒ [0 2§
0) 04 « ®
§ @ E/ 6 G E C3 U)
M
/
z E
0
§ § E
§ § § 0 [ z co CL
LU < § § z z k 2 k
§ 2 § § W w § < 0 d
o o W W w w W o o \
m s o u < < o m N CL
7 < 00
§ k °
2 \
W \§ R
/ 7 /
} \ § %
k 4 - a c
z % C * §
W 2 / 2
2 g
d) C)
I
w o
§ a W / \ ®
#
®rl- GGG -
¥ Q z = / & £ w
LO
� w w - ®
! 04 � _ � c - m < c W o � i o o c « I
T Q 3 A v 7 7 7 E 7 ] � / u §
ƒ a ~ _G ƒ % 2 \ z R E _ \ @ m
2 § \ & 2a # § & k $ / 0 0 \ 0 IL z
o 0
\ 0 - / ¥ ƒ c q 2
< $ f CL ° k w k
| m � k
\g� § k / / § W \ a § \ 15
\ ca 0
o «
? 1R F- k w S / U § W \ C / ¥ ¢ 6 §
oRu < � 02 ° =) -1 c ƒ c z E
«
Ln F-§ § § k § E & § % 0 3 o t / 4) R
z o z « 0 � z z < o CL § \ / / / \ 10
o W o ■ W o w 0 0 0
«± o a o < a. < � o o n « '
D O O O
G
N
E N
O G
r-. N
N�
c
m L
U tll
m N
C
0.0
Q
�W
N
N
N
C
CL 0 0
X 0 a1
a� 5
tw o 0
cc
co 0 w
10 LU
�
E
T_ w � w
Co y w y H
O G _Z Z
a> mz V W
C H ce O W
O f0 U F-
G U Q
c-0 It
w w 3
am u
w x
o 0 o
E0.-
a
—
G
N
O N
co Ow0 1— W w w
�.O-.L Q Q Q Q
E m
'm w
U'O
-- C
Co Co
Co
a m
O U
m N
3 0
o
a) m
6m
Co
0
0
U.'a
W W
CG
ON
U Q
O
+L U
N O
'p U1
O O !ll 111 W
rn`o H V1
CO 2 F U)
U o` 0 D Q k
LLI LU
v m Z Z Z Z
rn Co 0 F- a 0
C -o •- Z a a W w
c m m O D
m o 4D LLI IL=
(L)
_ °
% j \ §
Cl) _
� ® 00 69
%
a
§
z o
k
S k
� §
§
k
k
tL >
+ §
@
§
§
E E �
k (ColtL
.
§ co
z e
d §
\
0
i
\
C0
) z
� A
bf
\ \
LU
§ c LL
�
3
M §
In \ §
m § §U) \
\ \
@ m § §
§ §
SQ
E o §
§
/ § z K w co
) } § o E
\ / IL \ z §
4-
4-
0
qKt
d)
m
m
IL
m
rn
d °rte'
to o
z co
a 61)
w
a
a
0
w
z
a
x
U
C
7
O
E
a
M
O
m
01
rr
m
V
Y
O
N
N
I-
00 00
of J
O Q
U
o O
J
N
LU E
p � m
0 0
IL
z
0
o n
U LL r