Laserfiche WebLink
DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />DpnnfsdfDfoufsBsdijufduvsbmQsfdbtuDpodsfufQbofmt <br />22:.141S2 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />4.35.315.39.31 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />Jodmveft; <br />.Wbmvffohjoffsjohjufnt<Efevdu%382-611/11 <br />.Sfeftjhogpsqbofmdibohfsfrvftut<Bee%84-687/11 <br />.Beeqbofmfsfdujpoboedbvmljohjoupqspkfdu<Bee%973-835/11 <br />Attachments: (List documents support changerequired) <br />Opof <br />775-911/11 <br />Amount of Increase / Decrease: $____________________ <br />Categories (Pick One): <br />1/11 <br />o <br />Scope of Work <br />Previously approved Change Order(s): $___________________ <br />Differing Site Conditions, Changed Conditions <br />26/44 <br />Current Percent of Change: ____________________ % <br />Conflicted Specifications and Drawings <br />Failed Materials <br />6-111-111/11 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />26/44 <br />Total Percent of Change: ____________________ % <br />Final Quantity Adjustment <br />_______________________ <br />SFEBUJG <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />Ejhjubmmz!tjhofe!cz!Ebojfm!Kpoft! <br />EO;!do>Ebojfm!Kpoft-!p>Djuz!pg!Tpvui!Cfoe-!JO!Fohjoffsjoh-! <br />pv>Qspkfdu!Jotqfdups-!fnbjm>ekpoftAtpvuicfoejo/hpw-!d>VT! <br />Ebojfm!Kpoft <br />EboKpoft5.26.31 <br />Ebuf;!3131/15/17!26;26;3:!.15(11( <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />Ejhjubmmz!tjhofe!cz!Upz!Wjmmb! <br />Upz!Wjmmb <br />1502603131 <br />UpzWjmmb <br />Ebuf;!3131/15/26!28;51;22!.15(11( <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />Ejhjubmmz!tjhofe!cz!\[bdibsz!Ivstu! <br />EO;!do>\[bdibsz!Ivstu-!p>Djuz!pg!Tpvui!Cfoe-!pv>Fohjoffsjoh!Ejwjtjpo! <br />.!Efqbsunfou!pg!Qvcmjd!Xpslt-!fnbjm>{ivstuAtpvuicfoejo/hpw-!d>VT! <br />\[bdibsz!Ivstu <br />\[bdiIvstu5.26.31 <br />Ebuf;!3131/15/26!26;22;32!.15(11( <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />Ejhjubmmz!tjhofe!cz!Lbsb!Cpzmft! <br />Lbsb!Cpzmft <br />LbsbCpzmft60803131 <br />Ebuf;!3131/16/18!1:;62;16!.15(11( <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />