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CONTRACT NO. R 3G8$1' <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />DATE OF SUBMISSION Ju 9.. 2 2€;18 <br />ONSET DATE OF CHANGEt�lrsl CHANGE ORDER TYPE 1{tf3 03;'Quanty lncreasi%t1ecrease <br />PROPOSED COST AND TIME ADJUSTMENT" <br />COST COST INCREASE / (DECREASE): $ (3U,000) <br />The cost adjustment shall include lump sum and estimated totaled unit -priced item costs. Attach a separate sheet of unit price items <br />including item description, unit of measurement, estimated quantity and unit price. <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF COST CHANGE: <br />E1.109.03 AlterOicquantities Z 109.05(a) Agreed Price ❑ 109 05(b) i orce Account d 109.65..O.Delay Casts <br />PROPOSED COST CHANGE INCLUDES: ©;Labor A Material :Equipment..'Lease Agreement <br />Subcontractor <br />TIME ADJUSTMENT <br />INCREASE / (DECREASE): <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />(work days) BO <br />Excusable, Nan Comperisable ❑ 108 0$(b) Excusable,Compensabfe <br />NOTE: If Compensable, attach details based on 109.05.2(a) Allowable Delay Costs. <br />Haanionai Intormatlon rnay pe enterea by the contractor. <br />CHANGE ORDER ORIGINATION: ❑ ,IND0T / LPA ®,;Contractor , <br />DOCUMENTS AFFECTED: <br />❑ Contract Specifications (ref. doc name/no.) <br />® Contract Plans (ref. doc name/no.) <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: <br />Ver, 10-23.17 <br />