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CHANGE ORDER REQUEST FORM <br />CONTRACT NO. R:39540 <br />UPON WRITTEN REQUEST FROM THE ENGINEER, PROVIDE ADDITIONAL DETAIL <br />DATE RECEIVED REQUEST FOR <br />[Select Date] <br />SUBMITTAL DATE OF <br />[Select Date] <br />ADDITIONAL DETAIL <br />ADDITIONAL DETAIL <br />DETAILED DESCRIPTION / JUSTIFICATION: <br />(include location(s), actions of contractor, owner, and other stakeholders, key events and related cause(s), discoveries, <br />discussions, meetings, and effect on the contract if no action is taken. Also include references to key documents attached <br />or available to support this change order request.) <br />Click hereto 9nter.text. <br />PROPOSED SOLUTION — ADDITIONAL DETAILS: <br />(include proposed scope of work, means & methods, materials, equipment, utility relocation required, subcontracted <br />scope and the effect on the contract schedule. Also include references to attached documents including, but not limited <br />to, sketches, calculations, photos, material information, and submittals and meeting minutes.) <br />Click herd to entertext <br />SIGNATURES <br />Contractor: _yy <br />Name: (print) J <br />(signature) <br />Date: 6t ^ 2 1 - zo 20 <br />Project Engineer/Supervisor: (signature is to acknowledge receipt of the document and does not signify agreement of the change order) <br />Name: (print) <br />(signature) <br />NOTE. The Contractor and PENS should retain a signed copy of this document for record. <br />Date: <br />pg. 2 <br />