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HomeMy WebLinkAbout2022-205-E-AMS-Custom Stone-Purpose extra digging and gravel at veterans memorial Chapel Hill due to bad soilRevised 07/20 ORANGE COUNTY CHANGE ORDER REQUEST NORTH CAROLINA _____________________________________________________________________________________________________________ _ Date: 05/19/2022 Project: Veterans Memorial- Chapel Hill Change Order No. 03 Department: AMS Department Address: 300 West Tryon St Project: Veterans Memorial Contractor: Custom Stone NC, Inc Contractor Address: 1001 Ellis Road, Durham NC 27703 Effective date of original contract: 10/06/2020 This change order increases decreases the contract time by days. Check here if no impact to contract time . Will this change order impact the date of substantial completion? Yes No. If yes, the amended date of substantial completion is: ______________________________________________________________________________________________________________ _ Full Description of Change: Extra digging and Gravel Installation. Labor and machine time to excavate to find suitable soil to build on top of, add 12" gravel bed to fill void to pour concrete on top of Reason for Change: Veterans Memorial Change Order Due to Bad Soils _____________________________________________________________________________________________________________ __ Original contract sum: $ 98338.00 Contract sum prior to this change order: $ 103274.00 Amount of this change order: $ 3150.00 Total sum of the contract including this change order: $ 106424.00 _______________________________________________________________________________________________________________ This change order is executed to amend the contract time or contract sum. It shall not be construed to impact the original contract, project, services, or work in any other manner. All other terms of the Original Contract remain in effect. Approved and executed this 19th day of May, 2022. _______________________________ _____________________________ _____________________________ Contractor Owner Architect (when retained) By:____________________________ By:___________________________ By:___________________________ DocuSign Envelope ID: 0DC578EB-CB9B-4E2F-87EE-B72C1A252F0D 5/23/2022 5/24/2022 Revised 07/20 DocuSign Envelope ID: 0DC578EB-CB9B-4E2F-87EE-B72C1A252F0D ORANGE COUNTY—DEPARTMENT USE ONLY _____________________________________________________________________________________________________ Party/Vendor Name: Custom Stone NC, Inc Party/Vendor Contact Person: Daniel Benner Contact Phone: 919-682-8868 Party/Vendor Address: 1001 Ellis Drive City Durham State: NC Zip: 27703 Department: AMS Amount: $3150 Purpose: Extra Digging and Gravel at Veterans Memorial Chapel Hill due to bad soil Budget Code(s): 61370035-880000-10060 Vendor # 57997 Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date Approved by Board Yes No Agenda Date: This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: Department Director’s Signature ________________________________________ Date: ________ Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board __________________________________________Date:_________ Revised 07/20 DocuSign Envelope ID: 0DC578EB-CB9B-4E2F-87EE-B72C1A252F0D 5/23/2022 5/23/2022 5/24/2022 5/24/2022 Estimate Date 5/19/2022 Estimate # 9417C Customer Orange County Public Works 131 E Margaret Ln, Hillsborough, NC Custom Stone NC Inc. 1001 Ellis Road Durham, NC 27703 Job Name Orange County Vet... Signature Total Description Qty Price Amount Change Order Orange County Veterans Memorial Extra Digging and Gravel Installation Labor and machine time to do the following scope of work: -over excavate to find suitable soil to build on top of -add 12" washed stone bed to fill void prior to pouring footers 1 3,150.00 3,150.00 _____________________________... $3,150.00 DocuSign Envelope ID: 0DC578EB-CB9B-4E2F-87EE-B72C1A252F0D 05/20/2022 Pelnik Insurance 100 Ridgeview Drive Suite 100 Cary NC 27511 Steven Stacy (919) 459-8000 (866) 714-3576 Steve.Stacy@Pelnik.com Custom Stone NC Inc 704A Ramseur St. Durham NC 27701 Berkley Southeast Insurance Group Builders Mutual Ins CL219221899 A Y CPA 4509194 09/01/2021 09/01/2022 1,000,000 500,000 15,000 1,000,000 3,000,000 3,000,000 Employee Benefits 3,000,000 A CPA 4509194 09/01/2021 09/01/2022 1,000,000 A 0 CPA 4509194 09/01/2021 09/01/2022 2,000,000 2,000,000 B Y PWC14015689-0 09/01/2021 09/01/2022 1,000,000 1,000,000 1,000,000 A Leased and Rented Equipment CPA 4509194 09/01/2021 09/01/2022 Limit $100,000 Deductible $1,000 Orange County is included as additional insured with regards to General Liability Orange County PO Box 8181 Hillsborough NC 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY DocuSign Envelope ID: 0DC578EB-CB9B-4E2F-87EE-B72C1A252F0D DocuSign Envelope ID: 0DC578EB-CB9B-4E2F-87EE-B72C1A252F0D DocuSign Envelope ID: 0DC578EB-CB9B-4E2F-87EE-B72C1A252F0D