SAMPLE CHANGE ORDER - Centerton, Arkansas

CONSTRUCTION CHANGE ORDER FORM

Select a Name

To: ______________________

From: ____________________

Centerton Planning Project Coordinator

Individual to be contacted regarding this change.

Centerton Planning¡¯s Project # : _________________

Change Order # ________ Submittal # _______

Owner: ____________________________________

_______________________________________

Description of Change:

Project Name: _________________________________

Date Submitted: _____/_____/_____

Engineer:

Reason for Change:

Plan Sheets being Revised:

X_________________________________

Project Engineer

_______________

Date

Project Engineer is responsible for notifying the

Contractor of approval or denial of this Change

Order.

CITY STAFF USE ONLY:

?

Approved

Comments:

?

Denied

X

City Engineer

Date

Rev. 8/2/19

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