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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />XftufsoBwfovfTusffutdbqfQibtfJJJ <br />229.1875 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />503603131 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />.Beefedptugps3.TmjejohHbuftupCvtjofttft)EDJ*-,%34-195/92/ <br />.Beejujpobmdptugpsdpotusvdujpotubljohevfupeftjhofmfwbujpodpogmjdut-,%2-634/61/ <br />.BeefeHbufgpsIpuxiffmtBmmfz-,%4-:2:/76/ <br />.BeejujpobmQvodimjtuJufnt-,%7-2:9/43/ <br />Attachments: (List documents support changerequired) <br />Dpousbdupstqsjdjoh'xpslpsefst/ <br />45-837/39 <br />Amount of Increase / Decrease: $____________________ <br />Categories (Pick One): <br />286-266/42 <br />Scope of Work <br />Previously approved Change Order(s): $___________________ <br />Differing Site Conditions, Changed Conditions <br />2/35 <br />Current Percent of Change: ____________________ % <br />Conflicted Specifications and Drawings <br />Failed Materials <br />3-955-377/:5 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />8/:8 <br />Total Percent of Change: ____________________ % <br />Final Quantity Adjustment <br />_______________________ <br />435.2161.571.53.14 <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />KptiFinfs503603131 <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />Ejhjubmmz!tjhofe!cz!Upz!Wjmmb! <br />Upz!Wjmmb <br />1601803131 <br />UpzWjmmb <br />Ebuf;!3131/16/18!18;64;69!.15(11( <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />Lzmf!Tjmwfvt! <br />LzmfTjmwfvt602:03131 <br />3131/16/2:!26;11;63!.15(11( <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />