SAMPLE PROJECT CHANGE ORDER REQUEST FORM

PROJECT NAME	Cartman & Associates Front-Office Overhaul
LOCATION OF WORK	1200 Pike Place, 1st Floor
CONTRACT NO.	R7-625A1	CHANGE ORDER NO.	107
REQUESTING PARTY	Calista Schultz	DATE OF REQUEST	January 5, 2025
PROJECT MANAGER	Jack Peterman	CONTRACTOR	Peterman Construction
OWNER	Feldman Holdings	ENGINEER	Joel Richardson

PROJECT DETAILS
Front Office overhaul of Cartman & Associates

PROJECT CHANGE REQUEST DESCRIPTION
DESCRIPTION OF CHANGES NEEDED	4 additional laborers to meet revised deadline of one week earlier as stipulated by client
REASON FOR CHANGE	Client has requested a revised date of completion from Friday, March 14, 2025 to Friday, March 7, 2025. Additional manpower required.
SUPPORT & JUSTIFICATION DOCUMENTS	List all attached documents which support the requested change and justify any increased cost and time.
- Client Change Order Request 106b - PO A1-612
SPECIFICATIONS
IMPACT OF CHANGE	Project budget to increase by $11,125; Timeline impact: Project Deadline / Date of Completion change by 7 days from 03/14/2025 to 03/07/2025
RISK MANAGEMENT	No new risks introduced by change

PROJECT NAME	Contract No.: Cartman & Associates Front-Office Overhaul
LOCATION OF WORK	1200 Pike Place, 1st Floor
CONTRACT NO.	R7-625A1	CHANGE ORDER NO.	107

CHANGE IN CONTRACT PRICE	CHANGE IN CONTRACT TIMES
ORIGINAL PRICE	$127,550	ORIGINAL TIMES	03/14/2025; 133 days
NET CHANGES OF PREVIOUS CHANGE ORDERS	$138,675	NET CHANGES OF PREVIOUS CHANGE ORDERS IN DAYS	03/07/2025; 126 days
NET INCREASE / DECREASE	$11,125	NET INCREASE / DECREASE	(7 days)
TOTAL CONTRACT PRICE WITH APPROVED CHANGES	$138,675	TOTAL CONTRACT TIME WITH APPROVED CHANGES	126 days

CHANGE REQUEST PRIORITY LEVEL	PRIORITY LEVEL JUSTIFICATION

PROJECT CHANGE ORDER DISCUSSION DOCUMENTATION

CHANGE HAS BEEN DISCUSSED WITH:

NAME & TITLE	NAME & TITLE	DATE
By
By
By
By
By
By

RECOMMENDED BY ENGINEER	APPROVED BY OWNER
DATE	DATE
ACCEPTED BY CONTRACTOR	REVIEWED BY FUNDER
DATE	DATE

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