CN-550000-ASY81-W0010000.pdf

DocuSign Envelope ID: 299FD37B-7D1 F-4801-99E5-3951BD8D9C13

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

RAILROAD CHANGE ORDER NUMBER 1

Financial Project ID Roadway Description County Roadway ID

441664-1-57-01 SR 553 (N Park Rd) Hillsborough 10030002

725-090-04A

RAIL

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Contract ID

A. 1. The CSX 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:

PE Review of Plans Submittals for Resurfacing Project. This includes any other work deemed necessary for this project.

Crossing 624313P - Milepost A 860.09

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

Railroad Agreement.

3. The items of work covered by this Change Order are referenced to the Master Agreement of record dated 9/15/1998 and no Supplemental Agreement is required.

Agreement Type: Preliminary Engineering

B. 1. Reimbursement for the cost of this Railroad Work is to be in accord with the provisions set forth in Administrative Rule

Chapter 14-57 Section .011(2) as:

C.

CHANGE

ORDER

a. D NONREIMBURSABLE

b. � REIMBURSABLE

(1) � Force Account Method

(2) D Lump Sum Method

(3) D Third Party Contract Method

ESTIMATED COST OF WORK DUE TO THIS CHANGE ORDER

PREVIOUSLY

DESCRIPTION AUTHORIZED WORK

AMOUNT(S)

PE Review $

NEW AUTHORIZED

WORK AMOUNT

$10,000.00

Total amount of work previously authorized .................................................................. $

Total amount of new work authorized by this change order .............................................................................. $10,000.00

Total amount of work authorized under agreement for this Financial Project ID ............................................. $10,000.00

PROJECT TOTAL AMOUNT OF WORK AUTHORIZED TO DATE ................................................................................. $10,000.00

Examined as to provisions and participating items of cost:

02/09/2024 I 2:50 PM EST 02/09/2024 I 3:55 PM EST

Recommended: ________ _

Date

99Ml"�l'.ll"l"FF7448.

District Rail Administrator

Kenneth Madden

Approved: ________ _ Date

I CDBAE3f 8480400 ...

Director of Transportation Development

Justin Hall

ASY81

DocuSign Envelope ID: 299FD37B-7D1F-4B01-99E5-3951BD8D9C13

The Company shall:

EXHIBIT A

725-090-04A

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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.

DocuSign Envelope ID: 299FD37B-7D1F-4B01-99E5-3951BD8D9C13

The Company shall:

EXHIBIT B

725-090-04A

RAIL

OGC-12/23

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.

DocuSign Envelope ID: 299FD37B-7D1 F-4801-99E5-3951BD8D9C13

The Company understands:

EXHIBIT C

725-090-04A

RAIL

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1. that while FHWA 1273 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.

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?

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

Project Requirements:

Buy America

Additional procurement restrictions (Please describe below)

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)

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.)

Other If you selected Other, please describe below. Only complete this section if this project is associated with Federal and/or State funds.

Project Sponsor Bill To Information

Agency - Sponsor:

Billing Address:

Contact Name:

Phone:

E-mail:

Invoice Delivery Method:

Project Location:

Project Description:

Sponsor Project Ref.

Number (If applicable)

Signature of Applicant* Please sign, this form to the authorized CSX representative.

Name and Title of Applicant

Signature of Applicant Date:

*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.

Form Revision 7/ /23