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�4 <br />�wDEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />1 1 7-031 R Walo,VWorls Nudh Pumping Station Well �2e�ykwum�sm�41 <br />Project Number: Project Name: Change Order #: <br />DATE INITIATED; 6/18/2019 BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />Additional Cost for unanticipated Bypass Pumping Labor and Traffic Control. <br />Attachments: (List documents support change — required) <br />Bypass Pumping Labor and Traffic Control Cost Breakdown. <br />Amount of B Increase/ ❑ Decrease: $ 9462.72 <br />[Categories (Pick One): <br />Previously approved Change Order(s): $ 0 ❑ Scope of Work <br />..... _ ® Differing Site Conditions, Changed Conditions <br />Current Percent of Change: 1 .78 <br />❑ Conflicted Specifications and Drawings <br />❑ Failed Materials <br />New Total Amount: $ 542,225.72 <br />❑ Error <br />❑ Omission <br />Total Percent of Change: 1 .78 <br />," p n 1 ❑ Final Quantity Adjustment <br />Funding Secured From: IT�uV� Ct�'1 <br />11 <br />(filled out by PM) <br />RECOMMENDED BY: <br />Josh Ehmer 6/24/2019 <br />Project Inspector (Print Name) (Signat ) (Date) <br />REVIEWED BY: ti <br />Construction Manager (Print Name) (Signature) (Date) <br />APPROVED BY: <br />Engineering Project Manager (Print Name) (Signature) (Da e) <br />APPRO ED BY: <br />0 <br />City E ineer (Print am,) (sign turq) (Date) <br />