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CONTRACT NO. R-39514 <br />i <br />PROJECT DESCRIPTION <br />(route / intersection /bridge no(s).) <br />CHANGE ORDER REQUEST SUMMARY <br />DESCRIPTION <br /># _ j <br />DATE OF SUBMISSION October 7, 2019 { <br />Lasalle SRTS <br />Over -Run / Under -Run <br />PROPOSED SOLUTION SUMMARY Address under -runs on project over $20,000 <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />i 1 _ <br />ON <br />SET DATE OF CHANGE October 7, 2017 CHANGE ORDER TYPE 1 109.03 Quanty Increase/Decrease <br />PROPOSED COST AND TIME ADJUSTMENT <br />COST COST INCREASE / (DECREASE): $-$64,937.270 <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 />® 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 ❑ Equipment ❑ Lease Agreement ❑ Subcontractor <br />TIME ADJUSTMENT INCREASE / (DECREASE): (workdays) t , Days <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />❑ 108,08(a) Excusable, Non-Compensable ❑ 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: <br />DOCUMENTS AFFECTED: <br />❑ Contract Specifications (ref. doc name/no.) <br />❑ Contract Plans (ref, doc name/no.) <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: <br />® INDOT/LPA <br />None <br />Click here to enter text. <br />i <br />Click here to enter text. <br />❑ yes ® no (If yes, attach details) <br />❑ Contractor <br />Ver 10 18 18 <br />