CN-550000-E4Q69-00060000.pdf

-04

RICK SCOTT

GOVERNOR

Centennial., ..01110 :2015

Florida Department of Transportation 3400 West Commercial Boulevard Fort Lauderdale, FL 33309-3421

JIM BOXOLD

SECRETARY

MEMORANDUM

Date: Tuesday, September 01, 2015

TO: Contract Payment Section M/S 42

FROM: Becky B. Johnson, District 4 Construction Contracts Administrator

COPIES: File

SUBJECT: TRANSMITTAL OF APPROVED SUPPLEMENTAL AGREEMENT

Please find enclosed the approved Supplemental Agreement/Change Order 2 dated 8/31/2015 in the amount of $0.00 and 0 days for the following project:

Secretary or Designee Ignature

Printed Name Francis Lewis, P.E.

Title

Date

Executed

Broward Operations Engineer

Secretary or Designee

Printed Name

Title ture rolyn Gish, P.E.

strict Construction E in

(SEAL) COMPANY WESTERN SU' —_ .41•01

Date

Secretary AYNE D. WEE Y

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

SUPPLEMENTAL AGREEMENT

700-010-45

CONSTRUCTION

04/11

No. 002 Contract No.: E4Q69

Road No(s). SR 845 Federal Aid Project No(s). N/A

Fin. Proj. ID 436542-1-52-01

This agreement entered into on 614,( 1.4- 3/ .20/.5" , such an agreement to be effective on the last date of execution by a party hereto, by and been the State of Florida Department of Transportation "Department", and Weekley Asphalt Paving, Inc. "Contractor", and

Western Surety Company

"Surety", the same being supplementary to Contract No. E4Q69 by and between the parties aforesaid, dated

1/27/2015 for the construction or improvement of the road(s) and bridge(s) assigned the project number(s) shown above, in Broward Count(y)(ies) Florida.

(1) The Department and the Contractor hereby amend this contract as follows:

(Continued on page 2, attached hereto and made a part hereof.)

Revised Plan Sheet Nos. N/A

(2) The quantities to be paid shall be determined as provided in the Standard Specifications, Edition of 2014 The quantities so determined shall be paid at the unit prices stated on the attached sheets.

(3) It is further agreed that this supplemental agreement shall not alter or change in any manner the force and effect of the original Contract No. E4Q69 , including any previous amendments thereto, except insofar as the same is altered and amended by this supplemental agreement.

(4) The Department and the Contractor agree that the contract time adjustment and sum agreed to in this Supplemental Agreement constitute a full and complete settlement of the matters set forth herein, including all direct and indirect costs for equipment, manpower, materials, overhead, profit and delay relating to the issues set forth in the Supplemental Agreement. This settlement is limited to and applies to any claims arising out of or on account of the matters described and set forth in this Supplement Agreement.

Granted Time this Agreement 0 Days

Net Change in Contract Amount this Agreement: Increase No Change

Approved By:

$0.00

Decrease $0.00 ted By:

Date

(SEAL)

Contractor Signature

Printed Name .0/-)/\JII.L. 0. Wii-I<Li)/ Title /°4Z5 2I&)

Attorney igri ur artment of Transportation, Legal Review BY

P edifclame to lk-.2; / fl 08/20/15

11171 Flor , -ed gent Date

LISETTE ROD' GUEZ , ATTORNEY IN FACT

Sure

700-010-45

CONSTRUCTION - 04/11

No. 002 Contract No.: E4Q69

Road No(s). SR 845 Federal Aid Project No(s). N/A

Fin. Proj. ID 436542-1-52-01

(1) continued:

(A) Add new pay items to the contract . These pay items were not in the original contract but are needed to complete work documents BR-1-2015 and BR-2-2015 which have been issued from District 4 Traffic Operations to Broward Operations Center. Also add a negative adjustment pay item 9999-3 generic contract change "Budgetary Ceiling Item- For Accounting Purposes Only", since this is a Push-Button Contract, and due to budgetary restrictions, this negative pay item will make this SA a zero dollar contract change.

Rpt-ID: RCOCORPT

Florida Date: 08/13/2015

User: cn412tb

Department of Transportation Page:3 off

Change Order Report

Contract ID: E4Q69

Change Order Nbr: 002 Force Acct ID: 0

Change Order Type: Supplemental Aggreement

CO Description: Add Pay Items to Contract

Zero Dollar Change Order: No

Project Nbr ltm Nbr Catg Item Code Unit Unit Price Bid Qty Prey Apprvd Qty Curr CO Qty Curr Apprvd Qty Amount of Change

43654215201 0031 0200 0110 2 1 AC $3,385.00 0 0 0.01 0 This Chng: $33.85

Item Description CLEARING & GRUBBING (PUSH BUTTON CONT) CO Item Description Prey Revised: $0.00

New Revised: $33.85 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $33.85

Pct Change:

43654215201 0032 0200 0110 4 SY $27.00 0 0 24.4 0 This Chng: $658.80

Item Description REMOVAL OF EXISTING CONCRETE PAVEMENT CO Item Description Prey Revised: $0.00

New Revised: $658.80

Supplemental Description) New pay item for work document BR-3-2015 Bid Contract: $0.00

Supplemental Description2 Net Change: $658.80

Pct Change:

43654215201 0042 0200 0520 1 10 LF $49.00 0 0 110 0 This Chng: $5,390.00

Item Description CONCRETE CURB & GUTTER, TYPE F CO Item Description

New Revised: $5,390.00

Supplemental Description) New pay item for work document BR-3-2015 Bid Contract: $0.00

Supplemental Description2 Net Change: $5,390.00

Pct Change:

43654215201 0043 0200 0522 1 SY $58.00 0 0 60 0 This Chng: $3,480.00

Item Description CONCRETE SIDEWALK AND DRIVEWAYS, 4" CO Item Description

New Revised: $3,480.00

Supplemental Description) New pay item for work document BR-3-2015 Bid Contract: $0.00

Supplemental Description2 Net Change: $3,480.00

Pct Change:

User: cn412tb

Florida

Department of Transportation

Date: 08/13/2015

Page:4 ofi

Project Nbr ltm Nbr Catg Item Code Unit Unit Price Bid Qty Prey Apprvd Qty Curr CO Qty Curr Apprvd Qty Amount of Change

43654215201 0044 0200 0527 2 SF $40.00 0 0 77 0 This Chng: $3,080.00

Item Description DETECTABLE WARNINGS CO Item Description Prey Revised: $0.00

New Revised: $3,080.00 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $3,080.00

Pct Change:

43654215201 0101 0200 0632 7 2 LF $6.70 0 0 550 0 This Chng: $3,685.00

Item Description SIGNAL CABLE, REPAIR/REPL-FUR & INSTALL CO Item Description Prey Revised: $0.00

New Revised: $3,685.00 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $3,685.00

Pct Change:

43654215201 0102 0200 0635 2 40 EA $700.00 0 0 1 0 This Chng: $700.00

Item Description PULL & SPLICE BOX, RELOCATE CO Item Description Prey Revised: $0.00

New Revised: $700.00 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $700.00

Pct Change:

43654215201 0103 0200 0646 1 11 EA $1,600.00 0 0 4 0 This Chng: $6,400.00

Item Description ALUMINUM SIGNALS POLE, PEDESTAL CO Item Description Prey Revised: $0.00

New Revised: $6,400.00 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $6,400.00

Pct Change:

43654215201 0104 0200 0646 1 60 EA $424.27 0 0 1 0 This Chng: $424.27

Item Description ALUMINUM SIGNALS POLE, REMOVE CO Item Description Prey Revised: $0.00

New Revised: $424.27 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $424.27

Pct Change:

43654215201 0106 0200 0653191 AS $900.00 0 0 8 0 This Chng: $7,200.00

Prey Revised: $0.00 Item Description PEDESTRIAN SIGNAL, F&I, LED-COUNT DWN, 1 CO Item Description

New Revised: $7,200.00 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $7,200.00

Florida

Date: 08/13/2015

User: cn412tb

Department of Transportation Page:.3"of, Project Nbr Itm Nbr Catg Item Code Unit Unit Price Bid Qty Prey Apprvd Qty Curr CO Qty Curr Apprvd Qty Amount of Change

43654215201 0107 0200 0665 1 11 EA $323.79 0 0 8 0 This Chng: $2,590.32

Item Description PEDESTRIAN DETECTOR, F&I, STANDARD CO Item Description Prey Revised: $0.00

New Revised: $2,590.32 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $2,590.32

43654215201 0108 0200 0670 5400 AS $2,400.00 0 0 1 0 This Chng: $2,400.00

Item Description TRAF CNTL ASSEM, MODIFY CO Item Description Prey Revised: $0.00

New Revised: $2,400.00 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $2,400.00

43654215201 0111 0200 0700 1 11 AS $500.00 0 0 4 0 This Chng: $2,000.00

Item Description SINGLE POST SIGN, F&I GM, <12 SF CO Item Description Prey Revised: $0.00

New Revised: $2,000.00 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $2,000.00

43654215201 0112 0200 0700 1 60 AS $45.00 0 0 4 0 This Chng: $180.00

Item Description SINGLE POST SIGN, REMOVE CO Item Description Prey Revised: $0.00

New Revised: $180.00 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract $0.00 Supplemental Description2

Net Change: $180.00

43654215201 0113 0200 0711 11123 LF $2.40 0 0 628 0 This Chng: $1,507.20

Item Description THERMOPLASTIC, STD, WHITE, SOLID, 12" CO Item Description

New Revised: $1,507.20 Supplemental Description) New pay item for work document BR-3-2015

Bid Contract: $0.00 Supplemental Description2

Net Change: $1,507.20

43654215201 0201 0200 9999 3 LS $-39,729.44 0 0 1 0 This Chng: $-39,729.44

Item Description GENERIC CONTRACT CHANGE(S/M ONLY) CO Item Description

New Revised: $-39,729.44 Supplemental Description) Bugetary Ceiling item for Accounting Purposes Only.

Bid Contract: $0.00 Supplemental Description2

Net Change: $-39,729.44

Total Value for Change Order 002 = $0.00

WESTERN SURETY COMPANY

.cas,a4P/7"--14e.--aul T. Bruflat, Vice President

WESTERN SURETY COMPANY

24141—lrrL.°/ L. Nelson, Assistant Secretary 65v

Western Surety Company

POWER OF ATTORNEY APPOINTING INDIVIDUAL ATTORNEY-IN-FACT

Know All Men By These Presents, That WESTERN SURETY COMPANY, a South Dakota corporation, is a duly organized and existing corporation having its principal office in the City of Sioux Falls, and State of South Dakota, and that it does by virtue of the signature and seal herein affixed hereby make, constitute and appoint

Jeffrey Samas, Robert Mc Minn, Richard Arcadio Rodriguez, Lisette Rodriguez, Individually of Coconut Grove, FL, its true and lawful Attomey(s)-in-Fact with full power and authority hereby conferred to sign, seal and execute for and on its behalf bonds, undertakings and other obligatory instruments of similar nature

- In Unlimited Amounts -and to bind it thereby as fully and to the same extent as if such instruments were signed by a duly authorized officer of the corporation and all the acts of said

Attorney, pursuant to the authority hereby given, are hereby ratified and confirmed.

This Power of Attorney is made and executed pursuant to and by authority of the By-Law printed on the reverse hereof, duly adopted, as indicated, by the shareholders of the corporation.

In Witness Whereof, WESTERN SURETY COMPANY has caused these presents to be signed by its Vice President and its corporate seal to be hereto affixed on this 15th day of June, 2015.

State of South Dakota

SS

County of Minnehaha

On this 15th day of June, 2015, before me personally came Paul T. Bruflat, to me known, who, being by me duly sworn, did depose and say: that he resides in the City of Sioux Falls, State of South Dakota; that he is the Vice President of WESTERN SURETY COMPANY described in and which executed the above instrument; that he knows the seal of said corporation; that the seal affixed to the said instrument is such corporate seal; that it was so affixed pursuant to authority given by the Board of Directors of said corporation and that he signed his name thereto pursuant to like authority, and acknowledges same to be the act and deed of said corporation.

My commission expires

February 12, 2021

4.0.0040..........."......4,04.4.000.00.

S S. ETCH I faRDNOTARY PUBLIC

SOUTH OAKOTAar, a a ••••••• .004.4 4 S. Eich, Notary Public

CERTIFICATE

I, L. Nelson, Assistant Secretary of WESTERN SURETY COMPANY do hereby certify that the Power of Attorney hereinabove set forth is still in force, and further certify that the By-Law of the corporation printed on the reverse hereof is still in force. In testimony whereof I have hereunto subscribed my name and affixed the seal of the said corporation this 2 0 day of AUGUST

Form F4280-7-2012

Authorizing By-Law

ADOPTED BY THE SHAREHOLDERS OF WESTERN SURETY COMPANY

This Power of Attorney is made and executed pursuant to and by authority of the following By-Law duly adopted by the shareholders of the Company.

Section 7. All bonds, policies, undertakings, Powers of Attorney, or other obligations of the corporation shall be executed in the corporate name of the Company by the President, Secretary, and Assistant Secretary, Treasurer, or any Vice President, or by such other officers as the Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant Secretary, or the Treasurer may appoint Attorneys in Fact or agents who shall have authority to issue bonds, policies, or undertakings in the name of the Company.

The corporate seal is not necessary for the validity of any bonds, policies, undertakings, Powers of Attorney or other obligations of the corporation. The signature of any such officer and the corporate seal may be printed by facsimile.