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µ "'0' <br />DEPARTMENT OF PUBLIC WORKS <br />DIVISION OF ENGINEERING <br />118-083B J.C.LAUBER SITE IMPROVEMENTS <br />Project Number: Project Name: <br />Change Order #: 3 <br />DATE INITIATED: 9/17/19 <br />BPW DATE`: <br />Brief Summary of Change Order; (Construction Change, Alternative, Substitution, Differing Instructions, Out of Scope, Etc.). <br />Found Underground Fuel Tank that had to be Disposed & Adjustment to Final Quantities. <br />Attachments: (List documents support change — required) <br />Sub -Contractor Work Order. <br />Amount of Blncrease / ❑Decrease: $ 8,882.38 <br />Categories (Pick One): <br />Previously approved Change Order(s): $ 407,485.00 <br />❑ Scope of Work <br />.................. <br />?' 8 <br />® Differing Site Conditions, Changed Conditions <br />Current Percent of Change: % <br />❑ Conflicted Specifications and Drawings <br />New TotaL.... ,l, 4 ,.... <br />Amount: 16,367.38 <br />❑Failed Materials <br />❑ Error <br />.._.._...................... <br />11.47 <br />❑Omission <br />Total Percent of Change:. _ % <br />® Final Quantity Adjustment <br />Funding Secured From: 4111 Its" ►dbb 42o <br />171 <br />(filled out by PM) <br />RECOMMENDED BY:s, <br />Josh Ehmer <br />n�� � p, <br />a <br />9/17/19 <br />Project Inspector (Print Name) <br />(Signatt <br />(Date) <br />REVIEWED BY: <br />_.1.. <br />Construction Mana er P ( <br />g runt Name) <br />(Signature) <br />(Date) <br />APPROVED BY: <br />Alf <br />Engineering Project Manager (Print Name) <br />(Signs re) <br />(Data) <br />APPROVE7Y: <br />(' I <br />City Engineer (Print Nar're) '` <br />(Signature) <br />(Date) <br />