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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />Tfxfs'NboipmfSfibcjmjubujpo <br />229.1:44 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />903603131 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />FmjnjobufMjofJufn$2)Ofx59#EphipvtfNboipmf.41(Efqui-%36:-611/11*-boebeeuif <br />beejujpobmczqbttbnpvoupg%2:4-671/11/Uijtxjmmsftvmujobdpousbduefevdujpopg%76-:51/11/ <br />Attachments: (List documents support changerequired) <br />DpousbdupsQspqptbm/ <br />76-:51/11 <br />o <br />Amount of Increase / Decrease: $____________________ <br />Categories (Pick One): <br />:6-214/21 <br />o <br />Scope of Work <br />Previously approved Change Order(s): $___________________ <br />o <br />Differing Site Conditions, Changed Conditions <br />.3/16 <br />Current Percent of Change: ____________________ % <br />Conflicted Specifications and Drawings <br />Failed Materials <br />4-264-54:/71 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />/:4 <br />Total Percent of Change: ____________________ % <br />Final Quantity Adjustment <br />_______________________ <br />752.17.713.61:.54:112 <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />KptiFinfs903603131 <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />1903703131 <br />UpzWjmmb <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />9037031 <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />