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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />426'42:X/KfggfstpoFyufsjpsSfopwbujpot <br />22:.1753 <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />:.21.31:.33.31 <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />Dvscboetjefxbmlxpslfmjnjobufegspnuifdpousbducfdbvtfpofpguifvujmjuzdpnqbojft <br />sfqmbdfejuxijmfepjohbmmfzxpsl/ <br />Attachments: (List documents support changerequired) <br />O0B <br />5-881/11 <br />Amount of Increase / Decrease: $____________________ <br />Categories (Pick One): <br />2-967/11 <br />Scope of Work <br />Previously approved Change Order(s): $___________________ <br />Differing Site Conditions, Changed Conditions <br />.:/:8 <br />Current Percent of Change: ____________________ % <br />Conflicted Specifications and Drawings <br />Failed Materials <br />54-186/11 <br />New Total Amount: $____________________ <br />Error <br />Omission <br />.7/45 <br />Total Percent of Change: ____________________ % <br />Final Quantity Adjustment <br />_______________________ <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDEDBY: <br />EboKpoft:.25.31 <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />1:02503131 <br />UpzWjmmb <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />\[bdiIvstu <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />LbsbCpzmft <br />City Engineer (Print Name)(Signature)(Date) <br /> <br />