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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />Tfxfs'NboipmfSfibcjmjubujpo <br />229.1:42 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />:02102:802503131 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />GpvoeefufsjpsbufetfxfstpoXftufsoBwfuibuoffefemjofeupqsfwfoudpmmbqtf/ <br />Bmtp-3TfxfsQjqfsvotxfsfgpvoeupcfuifjodpssfdutj{fjouifgjfme/ <br />Attachments: (List documents support changerequired) <br />Dpousbdupsqsjdjoh/ <br />81-249/11 <br />Amount of Increase / Decrease: $____________________ <br />Categories (Pick One): <br />1 <br />Scope of Work <br />Previously approved Change Order(s): $___________________ <br />Differing Site Conditions, Changed Conditions <br />3/36 <br />Current Percent of Change: ____________________ % <br />Conflicted Specifications and Drawings <br />Failed Materials <br />4-2:5-765/61 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />3/36 <br />Total Percent of Change: ____________________ % <br />Final Quantity Adjustment <br />_______________________ <br />753.1732.526/53.16)VujmjuzFyqfotf* <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />KptiFinfs210:02: <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />TvfFmmfoEpvesjdl7041031 <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />