CN-550000-ASV01-W0010000.pdf

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

RAILROAD CHANGE ORDER NO. 01

725-090-04A

RAIL

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Financial Project Number Road Name or Number County Name Parcel & R/W

Number FAP Number

445467-1-57-01 SR 60 Polk 1(16260-2201) N/A

A. 1. The CSX Transportation, Inc. Company is hereby authorized to observe the following changes in the plans and or specifications to the subject Railroad Agreement, and to perform such work accordingly, further described as:

Preliminary Engineering, Flagging Services and Wireline Agreement review for the installation of wireline conduit at grade separated crossing 624502L, RRMP SV 849.84, Polk County. This Change order includes any other work deemed necessary to complete this project.

2. Exhibit A, Exhibit B, and Exhibit C are attached to the Railroad Change Order and made part of the Original

Railroad Agreement.

3. The items of work covered by this Change Order are referenced to an Original Agreement of record dated 8/27/1998 and no supplemental Agreement is required.

Original Type: Crossing Surface Signals Flagging

B. 1. The Railroad Relocation Work is to conform to that shown by the railroad adjustment plans as:

a. _____ ATTACHED

b. X INCLUDED IN THE HIGHWAY CONTRACT PLANS

2. Reimbursement for the cost of this Railroad Work is to be in accord with the provisions set forth in Administrative Rule Chapter 14-57 as:

a. NONREIMBURSABLE – Section .011(2)

b. X REIMBURSABLE – Section .011(2)

(1) X Force Account Method

(2) Lump Sum Method

(3) Third Party Contract Method

C. ESTIMATED COST OF WORK DUE TO THIS CHANGE ORDER

ITEM

NO.

ITEM UNIT UNIT

PRICE

WORK ELIMINATED (-)

QTY AMOUNT

ADDITIONAL WORK (+)

QTY AMOUNT

Preliminary Engineering 0.00 25,000.00 Flagging Services Agreement Review

Sub-Totals ………………………………………………………………… $0.00 $25,000.00

Net Cost of Construction Changes, this order ………………………... $25,000.00 $25,000.00

Cost of Construction Changes, previously ordered ………………….. $0.00 $0.00

Net Total Cost of Construction Changes, to date…………………………………………….. $25,000.00

Contract Amount ………………………………………………………………………………… $0.00

Estimated Cost of Work Authorized, to date………………………………………………….. $25,000.00

Examined as to provisions and participating items of cost:

Recommended: Approved: Approved:

Date Date Date

Wendy Sands District Rail Administrator

Paul Simmons Modal Development Administrator

Division Administrator N/A

Federal Highway Administration

Grade SeparationX

DocuSign Envelope ID: 8978E89F-EF2B-45AA-A9C9-55D7DDABFBE6

1/4/2023 | 8:34 AM EST 1/4/2023 | 9:13 AM EST

725-090-04A

RAIL

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EXHIBIT A

The Company shall:

1. utilize the U.S. Department of Homeland Security’s E-Verify system to verify the employment eligibility of all new employees hired by the Company during the term of the contract; and

2. include an express requirement in any subcontract that subcontractors performing work or providing services pursuant to the state contract utilize the U.S. Department of Homeland Security’s E-Verify system to verify the employment eligibility of all new employees hired by the subcontractor during the contract term.

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EXHIBIT B

The Company shall:

1. adhere to all Buy America requirements (23 CFR 635.410) to ensure that all manufacturing processes of steel and iron occur in the United States; and

2. ensure that prefabricated items that contain steel must also comply with Buy America; and

3. provide Buy America certifications that include correct language, project information, and the material’s delivery date.

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EXHIBIT C

The Company understands:

1. that while FHWA1273 does not apply to force account work performed by rail companies, FHWA-assistance is subject to Title VI (42 U.S.C. § 2000d et seq); and

2. requires appropriate assurances by providing an executed Title VI / Nondiscrimination Assurance, including Appendices A and E.

FLORIDA DEPARTMENT OF TRANSPORTATION

FUNDS APPROVAL

ASV01

12/22/2022

CONTRACT INFORMATION

FUNDS APPROVAL INFORMATION

FUNDS APPROVED/REVIEWED FOR ROBIN M. NAITOVE, CPA, COMPTROLLER ON 12/22/2022

Action: Task Work Order

Reviewed or Approved: APPROVED

Organization Code: 55014010106

Expansion Option: A5

Object Code: 563000

Amount: $25,000.00

Financial Project: 44546715701

Work Activity (FCT): 127

CFDA:

Fiscal Year: 2023

Budget Entity: 55150200

Category/Category Year: 088716/23

Amendment ID: W001

Sequence: 00

User Assigned ID: CO#1

Enc Line (6s)/Status: 0001/04

Total Amount: $25,000.00

Contract: ASV01

Contract Type: AC - RR CROSSING-PE/INSTAL (RR-XING/PE)

Vendor Name: CSX TRANSPORTATION, INC.

Vendor ID: F546000720022

Beginning Date of This Agreement: 12/20/2022

Ending Date of This Agreement: 12/31/2050

Contract Total/Budgetary Ceiling:

Method of Procurement: R - RAILROAD/UTILITIES AGREEMENT

Description: PE, Flagging and Wireline Agreement reviews

Page1 of 1

To: Phillip.Chapman@dot.state.fl.us

_____ Other

*By signing this form you are authorizing CSXT to incur costs and bill against this project. Should the project be canceled, CSXT will bill the Project Sponsor for the incurred costs. In the event the Project Sponsor is unresponsive for 90 days or more, the project will be closed;

and the Project Sponsor will be final billed for all project costs incurred.

Project Location:

Sponsor Project Ref.

Number (If applicable)

Signature of Applicant Date:

Project Description:

CSX is subject to a state single audit as a recipient or subrecipient of funds (The only states that should apply here are FL or NC. FL must provide completed form DFS-A2-NS.)

If you selected Other, please describe below.

Name and Title of Applicant

Please describe the funding source for this project (i.e. INFRA, Section 130, State, County, Private, etc.).

Contact Name:

Phone:

E-mail:

State Suspended and Debarred (Note - All federally funded projects are already monitored against the federal sus/deb listings)

Davis-Bacon (Please only check this box if this is a construction project that may be performed by an outside party)

Project Sponsor Bill To Information

Agency - Sponsor:

Billing Address:

Project Requirements:

CSX TRANSPORTATION – NEW PROJECT INITIATION FORM

Please provide the following information so that CSXT is able to accurately and appropriately process the project setup and billing.

Is this project associated with Federal funds?

Is this project associated with State funds?

Additional procurement restrictions (Please describe below)

Buy America

Form Revision 9/6/19

DocuSign Envelope ID: F765F541-3950-4DFB-AEC3-81876A0A97A6

Phillip Chapman

801 N Broadway Ave. Bartow Fl 33830

X

FDOT - D1

445467-1-57-01 (ASV01)

E-Verify phillip.chapman@dot.state.fl.us

YES

Phillip Chapman

Flagging Services and Wireline Agreement review for Resurfacing Project

DDR State Funds

SR 60 FROM CR 555 TO BROADWAY AVE / Crossing #624502L

NO

X

12/28/2022

863-519-2437