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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />312:Efnpmjujpot-Qibtf3EjwC <br />22:.18:2 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />80803131 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />GjobmRvboujuzEfevdugpsopuvtjohFowjsponfoubmBmmpxbodf/ <br />Attachments: (List documents support changerequired) <br />21-111/11 <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 />.9/27 <br />Current Percent of Change: ____________________ % <br />Conflicted Specifications and Drawings <br />Failed Materials <br />223-676/11 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />.9/27 <br />Total Percent of Change: ____________________ % <br />Final Quantity Adjustment <br />5 <br />_______________________ <br />515/2312/526/4:/98 <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />KptiFinfs902103131 <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />1902103131 <br />UpzWjmmb <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />9028031 <br />LzmfX/Tjmwfvt <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />