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CHANGE ORDER REQUEST FORM <br />CONTRACT NO. R-39540 <br />UPON WRITTEN REQUEST FROM THE ENGINEER, PROVIDE ADDITIONAL DETAIL <br />F-- — <br />DATE RECEIVED REQUEST FOR SUBMITTAL DATE OF <br />i ADDITIONAL DETAIL [Select Date] ADDITIONAL DETAIL [Select Date] <br />DETAILED DESCRIPTION / JUSTIFICATION: <br />(Include location(s), actions of contractor, owner, and other stakeholders, key events and related couse(s), discoveries, <br />discussions, meetings, and effect on the contract if no action is taken. Also include references to key documents attached <br />or available to support this change order request.) <br />Click here to enter text. <br />PROPOSED SOLUTION — ADDITIONAL DETAILS: <br />(Include proposed scope of work, means & methods, materials, equipment, utility relocation required, subcontracted <br />scope and the effect on the contract schedule. Also include references to attached documents including, but not limited <br />to, sketches, calculations, photos, material information, and submittals and meeting minutes.) <br />Click here to enter text. <br />SIGNATURES <br />Contractor: <br />Name: (print) <br />(signature) Date: <br />Project Engineer/Supervisor: (signature is to acknowledge receipt of the document and does not signify agreement of the change order) <br />Name: (print) <br />(signature) Date: <br />NOTE: The Contractor and PE/s should retain a signed copy of this document for record. <br />pg. 2 <br />