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CONTRACT NO. R 3688'i <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />PATE OF SUBMISSION .Ittl�r.2 2{D'1$;: <br />ONSET DATE OF CHANGE CHANGE ORDER TYPE 104:02 Ctttiriged Cni3dttirtns : <br />PROPOSED COST ,AND TIME ADJUSTMENT <br />COST <br />COST INCREASE J (DECREASE): <br />$ ;'1138,364 94 <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 />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />® 108.(38(a) Excusable, Nan=Comperisable ' CI 1Q8.08(It)'Excusable'Comp;nsab[e <br />NOTE: If Compensable, attach details based on 109.05.2(a) Allowable Delay Costs. <br />SUPPLEMENTAL INFORMATION <br />Additional intorrnation €rtaV ne enterea pY the contractor. <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: <br />Ver. 10.23.17 <br />