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CHANGE ORDER REQUEST FORM <br />CONTRACT R-39540 DATE OF June 17, <br />NO. SUBMISSION 2020 <br />PROJECT DESCRIPTION IRONWOOD ROAD AND CORBY BLVD <br />(route / intersection / bridge no(s).) <br />CHANGE ORDER REQUEST SUMMARY Water service relocates J <br />DESCRIPTION <br />PROPOSED SOLUTION SUMMARY Relocate services due to conflicts <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />ONSET DATE OF CHANGE June 17, 2020 CHANGE ORDER TYPE 104.03 Extra Work <br />PROPOSED COST AND TIME ADJUSTMENT <br />COST INCREASE / 20,976.50 <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 <br />Subcontractor <br />TIME ADJUSTMENT <br />INCREASE / (DECREASE): <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />(work days) N/A <br />❑ 108.08(a) Excusable, Non-Compensable ® 108.08(b) Excusable, Compensable <br />NOTE: If Compensable, attach details based on 109.05.2(a) Allowable Delay Costs. <br />SUPPLEMENTAL INFORMATION <br />Additional information may be entered by the contractor. <br />CHANGE ORDER ORIGINATION_ IK INDOT/ LPA <br />401610I 40luu. ;l9ft ag <br />❑ Contract Specifications (ref. doc name/no.) <br />❑ Contract Plans (ref. doc name/no.) <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: <br />Click here to enter text. <br />Click here to enter text_ <br />❑ yes ® no (if yes, attach details) <br />❑ Contractor <br />Ver. 10.23.17 <br />