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CHANGE ORDER REQUEST FORM <br />CONTRACT R-38540 DATE OF <br />:3eptellnber'' <br />NO. SUBMISSION 21, <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />ONSET DATE OF CHANGE AmOuSt 2020 CHANGE ORDER TYPE %104:03 ExtraWork:.; <br />PROPOSED COST AND TIME ADJUSTMENT <br />COST COST INCREASE / (DECREASE): $ 1,.027.66'. <br />The cost adjustment shall include lump sum and estimated totaled unit -priced item costs. Attach a separate sheet of unit price Items <br />including item description, unit of measurement, estimated quantity and unit price. <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF COST CHANGE: <br />D 109.03 Altered Qyantitles 13-109.05(a} Agreed price ®109.05(b) Force Account D 109.05.OZ.DelayGosts.. <br />PROPOSED COST CHANGE INCLUDES: 0.1abor 0.0aterial 0 quipmerit . Q Lease Agreement <br />Subcontractor <br />TIME ADJUSTMENT INCREASE/(DECREASE): (work days)N/A <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />i].108.OS(aj Excusable, ln-Cornpensable.'_ .08(b) Excusable, Compensable <br />NOTE: if Compensabk, attach details based on 109.m.2(a) Allowable Delay Costs. <br />SUPPLEMENTAL INFORMATION <br />Additinnal Informatinn may ha s+nfamd by tha rnntr�.tn� <br />CHANGE ORDER ORIGINATION: <br />t INDOT-/ LPA .:: 0 Contractor '--_ <br />DOCUMENTS AFFECTED: <br />❑ Contract Specifications (ref. doc name/no.) <br />Clic .here to enter text <br />❑ Contract Plans (ref. doc name/no.) <br />Clli here to enter text- . <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: <br />❑ yes ® no (if yes, attach details) <br />Ver. 10.23.17 <br />