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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 /> Alicia Czarnecki 10/27/2020 <br />1/12/2021Kara M. Boyles