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DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />Project Number: _______________ Project Name: __________________________ Change Order #: ____ <br />DATE INITIATED:BPW DATE: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />Attachments: (List documents support change –required) <br />Amount of ܆Increase / ܆Decrease: $____________________Categories (Pick One): <br />܆ Scope of Work <br />܆ Differing Site Conditions, Changed Conditions <br />܆ Conflicted Specifications and Drawings <br />܆ Failed Materials <br />܆ Error <br />܆ Omission <br />܆ Final Quantity Adjustment <br />܆ _______________________ <br />Previously approved Change Order(s): $___________________ <br />Current Percent of Change: ____________________ % <br />New Total Amount: $____________________ <br />Total Percent of Change: ____________________ % <br />Funding Secured From: __________________________ <br />(filled out by PM) <br />RECOMMENDED BY: <br />Project Inspector (Print Name)(Signature)(Date) <br />REVIEWED BY: <br />Construction Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />Engineering Project Manager (Print Name)(Signature)(Date) <br />APPROVED BY: <br />City Engineer (Print Name)(Signature)(Date) <br />e)e <br />Jacob M. Klosinski 10/15/2020 Jacob M. Klosinski <br />116-082D Miami Basin Valve Replacement 1 <br />10/1/2020 <br />740.52 <br />0 <br />-.42 <br />175,259.48 <br />-.42 <br />Josh Ehmer 10/1/2020 <br />Toy Villa <br />10/15/2020 <br />Adjustment to final quantities.