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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 />tureeeeeee)))))))eeeeee <br />2/12/21Kyle W. Silveus <br />324-442001 <br />118-105 Washington Street Improvements 1 <br />11/19/2020 <br />Borrow Material Cost. <br />42,100.00 <br />0 <br />11.14 <br />420,000.00 <br />11.14 <br />Josh Ehmer 1/28/2021 <br />Toy Villa <br />02/01/2021 <br />Borrow Material ($6,000.13). <br />Adjustment to Final Quantities ($36,099.87).