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CONTRACT NO. ( R-39514-A <br />DATE OF SUBMISSION August 15, 2019 <br />PROJECT DESCRIPTION Lasalle SRTS <br />(route / intersection / bridge no(s).) <br />CHANGE ORDER REQUEST SUMMARY Intermediate Completion Date Time Extension due to utility delay and extra <br />DESCRIPTION work <br />PROPOSED SOLUTION SUMMARY Time extension for 7 days <br />i <br />NOTE, Upon request from Engineer, enter detailed description on page 2 <br />ONSET DATE OF CHANGE August 15, 2019 � CHANGE ORDER TYPE � 104 02 Changed Conditions <br />COST COST INCREASE / (DECREASE): $ $ 0.00 <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 />❑ 109.03 Altered Quantities ❑ 109.05(a) Agreed Price ❑ 109.05(b) Force Account ❑ 109.05.02 Delay Costs <br />PROPOSED COST CHANGE INCLUDES: ® Labor ® Material M Equipment ® Lease Agreement ❑ <br />Subcontractor <br />Addition 7 day <br />TIME ADJUSTMENT INCREASE / (DECREASE): (work days) time extension <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />-Z 108.08(a) Excusable, Non-Compensable ❑ 108.08(b) Excusable, Compensable <br />NOTE: If Compensable, attach details based on 109.05.1(a) Allowable Delay Costs. <br />SUPPLEMENTAL INFORMATION <br />Additional information may be entered by the contractor, <br />CHANGE ORDER ORIGINATION: <br />DOCUMENTS AFFECTED: <br />❑ Contract Specifications (ref. doc name/no.) <br />❑ Contract Plans (ref. doc name/no.) <br />❑ INDOT / LPA ® Contractor <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: ❑ yes Z no (if yes, attach details) <br />Vi, 101,3P7 <br />