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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />QvmbtljQbslJnqspwfnfout <br />229.1675 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />705031 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />BeefeTdpqf;SfqmbdfebnbhfeNpovnfouTjhoboejotubmmeppsmpdldpwfstposftusppn/ <br />Attachments: (List documents support changerequired) <br />QDS$115)GjobmD/P/* <br />3-112/11 <br />Amount of Increase / Decrease: $____________________ <br />Categories (Pick One): <br />28-951/61 <br />ScopeofWork <br />Previously approved Change Order(s): $___________________ <br />DifferingSite Conditions, ChangedConditions <br />/33 <br />Current Percent of Change: ____________________ % <br />ConflictedSpecificationsandDrawings <br />FailedMaterials <br />9:9-638/86 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />3/37 <br />Total Percent of Change: ____________________ % <br />FinalQuantityAdjustment <br />______________________ <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />HsfhNdHpxbo7022031 <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />