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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />GjsfTubujpoOpt/4boe7Sfopwbujpot <br />229.1583 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />5.7.315.39.31 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />.Mjhiujohvqhsbeftboesfuspgjutbucpuitubujpot4'7<boeBqqCbzbutubujpo4/ <br />.Ofxcbuisppngjyuvsftbutubujpo7 <br />Attachments: (List documents support changerequired) <br />Opof <br />39-671/11 <br />Amount of Increase / Decrease: $____________________ <br />Categories (Pick One): <br />.2:4-611/11 <br />o <br />Scope of Work <br />Previously approved Change Order(s): $___________________ <br />o <br />Differing Site Conditions, Changed Conditions <br />4/19 <br />Current Percent of Change: ____________________ % <br />Conflicted Specifications and Drawings <br />Failed Materials <br />:66-171/11 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />.25/84 <br />Total Percent of Change: ____________________ % <br />Final Quantity Adjustment <br />_______________________ <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />EboKpoft5.32.31 <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />1503203131 <br />UpzWjmmb <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />1503303131 <br />BmjdjbD{bsofdlj <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />LbsbCpzmft503303131 <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />