HomeMy WebLinkAbout17.f FYI CO 2 Potable Reuse_Fully ExecutedSECTION 00660
Change Order Request Form
00660-1
CCUA Project No.: 3019-001
EOR PROJECT No.: 11991B10 CHANGE ORDER REQUEST FORM
PROJECT NAME: CCUA Potable Reuse Demonstration Facility February 2020
Project: CCUA Potable Reuse Demonstration Facility Project No.: 3019-001________ Change Order No.:CO#002
Change in Contract Times
(Days)
(Days)
Original Contract time: Substantial Completion: 360 Ready for Final Payment:
Increased from previous C.O.: Substantial Completion: 196 Ready for Final Payment:
Decreased from previous C.O.: Substantial Completion: N/A Ready for Final Payment:
Contract time prior to this C.O.: Substantial Completion: 556 Ready for Final Payment:
Increase in time on this C.O.: Substantial Completion: 26 Ready for Final Payment:
Decrease in time on this C.O.: Substantial Completion: N/A Ready for Final Payment:
Contract time with all approved C.O.s: Substantial Completion: 582 Ready for Final Payment:
Change in Contract Price
Original Contract Price: $4,540,000.00
Increased from previously approved C.O.: N/A
Decreased from previously approved C.O.: N/A
Increase in Contract price this C.O.: N/A
Decrease in Contract price this C.O.: N/A
Contract price with all approved C.O.s: $4,540,000.00
The undersigned Contractor certifies to the best of my knowledge and belief: (1) all items and amounts shown above are correct; (2)
all Work performed and Reimbursable Expenses fully comply with the terms and conditions of the Contract Documents; (3) all
previous progress payments received from Clay County Utility Authority (CCUA) , on account of Work done under the Contract
referred to above have been applied to discharge in full all obligations of Contractor incurred in connection with Work covered by
prior Applications for Payment; (4) title to all materials and deliverables incorporated in said Work or otherwise listed in or covered
by this Application for Payment will pass to the CCUA at the time of payment clear of all liens, claims, security interests and
encumbrances; (5) payment is due and has not been previously requested for these amounts; (6) no markup has been applied to
reimbursable expenses.
Travis Cassella, Project Manager – Wharton-Smith, Inc.
Contractor Name and Title
SECTION 00660
Change Order Request Form
00660-2
CCUA Project No.: 3019-001
EOR PROJECT No.: 11991B10 CHANGE ORDER REQUEST FORM
PROJECT NAME: CCUA Potable Reuse Demonstration Facility February 2020
Cost Break Down Form: (instructions: use a separate form for each individual work item)
Description Unit Quantity Unit Cost Extended Cost
Labor $
Materials $
Equipment $
Maintenance of Traffic $
Bonding $
General Conditions $
Overhead and Profit $
$
$
Total firm fixed cost not to exceed amount: $
Note: attached supporting documentation
RFI No. initiating the change:
Description: No cost, contract time extension request
Justification for the request: Time extension request due to Square D. electrical gear package delay.
State the firm fixed cost not to exceed amount in words:
Contractor Signature: Date: April 1, 2024
Printed Name: Travis Cassella Title: Project Manager