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<< DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />r�aa <br />116-040 'WOR*a" � �� � ,a;a �� ��� G �� ,��� � ���,anM r�W� 1 <br />Project Number: Project Name: Change Order #: <br />DATE INITIATED: 9/16/19 BPW DATE:9/24/19 <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />Time Extension of 6 days due to utility delays by AEP. <br />Attachments: (List documents support change — required) <br />INDOT Change Order Form <br />Amount of ❑ Increase / ❑ Decrease: $ NSA <br />Categories (Pick One): <br />Previously approved Change Order(s): $ N/A ❑ Scope of Work <br />............................. — ......... ®----® ❑ Differing Site Conditions, Changed Conditions <br />Current Percent of Change: NSA % ❑ Conflicted Specifications and Drawings <br />New 1,589, 000 ❑ Failed Materials <br />Total Amount: $_ ❑ Error <br />❑ Omission <br />Total Percent of Change: 0.00 <br />❑ Final Quantity Adjustment <br />17-11 <br />Funding Secured From° _. .. <br />(filled out by PM) <br />RECOMMENDED BY. <br />Project Inspector (Print Name) (Signature) (Date) <br />REVIEWED BY: <br />Construction Manager ( (nt Name) (Signature) (Date) <br />APPROVED BY: <br />Engineering Project Manager (Print Name) (Signatu (Date) <br />APPROVED Y: <br />City Engineer (Print Name) (Signs v ) (Date) <br />