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CHANGE ORDER REQUEST FORM <br />CONTRACT NO. IR-39514 <br />UPON WRITTEN REQUEST FROM THE ENGINEER, PROVIDE ADDITIONAL DETAIL <br />DATE RECEIVED REQUEST FOR October 3, 2017 SUBMITTAL DATE OF October 7, 2017 <br />ADDITIONAL DETAIL ADDITIONAL DETAIL <br />I <br />DETAILED DESCRIPTION / JUSTIFICATION: <br />(Include location(s), actions of contractor, owner, and other stakeholders, key events and related cause(s), discoveries, <br />discussions, meetings, and effect on the contract if no action is taken. Also include references to key documents attached <br />or available to support this change order request.) <br />See attached Information <br />PROPOSED SOLUTION — ADDITIONAL DETAILS: <br />(Include proposed scope of work, means & methods, materials, equipment, utility relocation required, subcontracted <br />scope and the effect on the contract schedule. Also include references to attached documents including, but not limited <br />to, sketches, calculations, photos, material information, and submittals and meeting minutes.) <br />Refer to attachments <br />SIGNATURE <br />Contractor: <br />Name: (print) Ruben a 'o <br />LP � ) <br />(signature) „gin <br />,,�.... late: <br />NOTE: The Contractor should retain a signed copy of this document for record. <br />