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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 />Local Roads and Streets <br />251-06-600-506-442001 <br />8/18/2021