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CHANGE ORDER REQUEST FORM <br />CONTRACT NO. R-37497 <br />PROJECT DESCRIPTION <br />(route / intersection / bridge no(s).) <br />DATE OF SUBMISSION 5/5/2020 <br />ROAD RECONSTRUCTION ON BENDIX DRIVE FROM .10 <br />MILES NORTH OF LATHROP ROAD TO 1-80 <br />CHANGE ORDER REQUEST SUMMARY Edge of Pavement Revision Costs. After Changes where made anew <br />DESCRIPTION GPS model had to be made and sub grade needed to be regraded. <br />PROPOSED SOLUTION SUMMARY <br />NOTE: Upon request from Engineer, enter detailed description on page 2. <br />ONSET DATE OF CHANGE 4/20/2020 <br />PROPOSED COST AND TIME ADJUSTMENT <br />COST <br />COSTINCREASE/(DECREASE): <br />$ 4,166.80 <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 />111109.03 Altered Quantities ❑ 109.05(a) Agreed Price ❑ 109.05(b) Force Account ❑ 109.05.02 Delay Costs <br />PROPOSED COST CHANGE INCLUDES: ❑ Labor ❑ Material ❑ Equipment ❑ Lease Agreement B Subcontractor <br />TIME ADJUSTMENT <br />INCREASE/(DECREASE): <br />CHECK APPROPRIATE BOXES PER APPROPRIATE BASIS OF TIME CHANGE: <br />(work days) 5 <br />❑ 108.08(a) Excusable, Non-Compensable ❑ 108.08(b) Excusable, Compensable <br />NOTE: If Compensable, attach details based on 109.05.2(o) Allowable Delay Costs, <br />SUPPLEMENTAL INFORMATION <br />Additional information may be entered by the contractor. <br />CHANGE ORDER ORIGINATION: <br />DOCUMENTS AFFECTED: <br />❑ Contract Specifications (ref. doc name/no.) <br />❑ Contract Plans (ref. doc name/no.) <br />A INDOT/LPA <br />CHANGE ORDER AFFECTS DBE PARTICIPATION: W yes ❑ no (if yes, attach details) <br />❑ Contractor <br />