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CHANGE ORDER REQUEST FORM <br />CONTRACT NO. R- 39514 DATE OF SUBMISSION October 7, 2019 <br />PROJECT DESCRIPTION k Lasalle SIRTS <br />(route / Intersection / bridge no(s).) <br />CHANGE ORDER REQUEST SUMMARY i Intermediate Completion Date Time Extension due to extra work <br />DESCRIPTION <br />.... . ..... .. <br />PROPOSED SOLUTION SUMMARY Time Extension for 36 days <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />ONSET DATE OF CHANGE October 7, 2017 CHANGE ORDER TYPE 104.02 Changed Conditions <br />PROPOSED COST AND TIME ADJUSTMENT <br />COST COST INCREASE / (DECREASE): $ 0 <br />The cost adjustment shall include lump sum and/or 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 />0 109.03 Altered Quantities 0 109.05(a) Agreed Price El 109.05(b) Force Account 0 109.05.02 Delay Costs <br />PROPOSED COST CHANGE INCLUDES: El Labor El Material 0 Equipment El Lease Agreement El Subcontractor <br />Addition 36 <br />days <br />TIME ADJUSTMENT INCREASE / (DECREASE): (work days) Time Extension <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />0 108.08(a) Excusable, Non-Compensable 0 108.08(b) Excusable, Compensable <br />NOTE: If Compensable, attach details based on 109.05.2(a) Allowable Delay Costs. <br />SUPPLEMENTAL INFORMATION <br />Additional information. <br />CHANGE ORDER ORIGINATION: ❑ INDOT/LPA 0 Contractor <br />DOCUMENTS AFFECTED: <br />0 Contract Specifications (ref. doc name/no.) Click here to enter text, <br />C3 Contract Plans (ref. doc name/no.) Click here to enter text <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: ❑ yes 0 no (if yes, attach details) <br />