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CHANGE ORDER REQUEST FORM <br />ONSET DATE OF CHANGE <br />June 95, 2020 <br />CHANGE ORDER TYPE <br />:104,Oi IF16a Work <br />PROPOSED COST AND TIME ADJUSTMENT <br />COST <br />COST INCREASE / (DECREASE): <br />$ :.22,327.92. <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 />❑ 109.03Altered C�uantitles ❑ ib9 05(a) Agreed Price ® 109 05(b) Force Account. .❑ 109.05.02 Delay Costs.:_: <br />PROPOSED COST CHANGE INCLUDES: ❑Labor ❑ MaCeria! fO Equipment p Lease Agreement <br />Subcontractor: <br />TIME ADJUSTMENT INCREASE / (DECREASE): (work days) N/A <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />❑ 108 08(a} Excusable;Ncn-Compensable 11.109.08(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: <br />® IND07/ LPA CI Contractor <br />DOCUMENTS AFFECTED: <br />❑ Contract Specifications (ref. doc name/no.) <br />CIldc.here to entertexL <br />❑ Contract Plans (ref. doc name/no.) <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: <br />Click here to enter text. - <br />❑ yes N no (if yes, attach details) <br />Ver. 10.23.17 <br />