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CHANGE ORDER REQUEST FORM <br />CONTRACT R-39540 <br />NO. <br />DATE OF July 15, <br />SUBMISSION 2020 <br />PROJECT DESCRIPTION IRONWOOD ROAD AND CORBY BLVD <br />(route / intersection / bridge no(s).) <br />CHANGE ORDER REQUEST SUMMARY THE CITY REQUESTED THAT TREES BE PLANTED FOR A BARRIER <br />DESCRIPTION TO THE DRY RETENTION BASIN. <br />PROPOSED SOLUTION SUMMARY PLAN 10 EA ARBORVITAE TREE AT 6' TO 8' TALL <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />[ONSET DATE OF CHANGE July 15, 2020 CHANGE ORDER TYPE -- 104.03 Extra Work <br />PROPOSED COST AND TIME ADJUSTMENT <br />COST INCREASE / 5,956.21 <br />COST(DECREASE): $.......................................................................................................... <br />The cost adjustment shall include lump sum and estimated totaled unit -priced item costs. Attach a separate sheet of unit price items <br />including item description, unit of measurement, estimated quantity and unit price. <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF COST CHANGE: <br />❑ 109.03 Altered Quantities ® 109.05(a) Agreed Price ❑ 109.05(b) Force Account ❑ 109.05.02 Delay Costs <br />PROPOSED COST CHANGE INCLUDES: ❑ Labor ❑ Material ❑ Equipment ❑ Lease Agreement Z <br />Subcontractor <br />TIME ADJUSTMENT <br />INCREASE / (DECREASE): <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />(work days) N/A ^J <br />❑ 108.08(a) Excusable, Non-Compensable ❑ 108.08(b) Excusable, Compensable <br />NOTE: If Compensoble, attach details based on 109.05.2(a) Allowable Delay Costs. <br />SUPPLEMENTAL INFORMATION <br />Additional information maybe entered by the contractor. <br />CHANGE ORDER ORIGINATION: <br />DOCUMENTS AFFECTED: <br />❑ Contract Specifications (ref. doc name/no.) <br />❑ Contract Plans (ref. doc name/no.) <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: <br />® INDOT/ LPA <br />Click here to enter text. <br />Click here to enter text. <br />❑ yes ® no (if yes, attach details) <br />0 Contractor <br />Ver. 10.23.17 <br />