Sample Only

City of Port Angeles, WA
Public Works Department Policy and Procedures
Design Clarification/Variation Request/Field Authorization Form

PROJECT NAME:________________
PROJECT NUMBER:________________
ORIGINATOR:________________
ITEM:________________
REFERENCE DRAWING OR SPECIFICATION:________________
DESCRIPTION OF REQUEST:________________
DATE REPLY REQUIRED:________________
CRITICAL TO SCHEDULE: YES_____ NO______
PROJECTED COST EFFECTS:________________
PROJECTED TIME EFFECTS:________________

COST INCREASE [APPROX. VALUE $ ] INCREASE IN CONTRACT TIME [ DAYS]

NO CHANGE IN PRICE NO INCREASE IN CONTRACT TIME

COST DECREASE [APPROX. VALUE $ ] DECREASE IN CONTRACT TIME [ DAYS]

ORIGINATOR SIGNATURE: DATE:

OWNER / ARCHITECT / ENGINEER

VARIATION REMARKS:

CLARIFICATION:

It is our opinion that this work is not an extra to the contract and direct the contractor to perform the work described per the contract documents. If you consider the above to be an extra to the contract, you must prepare and submit a detailed cost proposal and justification.

It is our opinion that this work will result in a need for a change order to the contract amount and/or time. You should prepare a detailed cost proposal and justification as soon as possible since the work will not be authorized until such data is approved. If such work is critical to the timely execution of the contract, you are authorized to proceed subject to the work not exceeding $ and days to the contract time. Final cost and time changes shall be subject to the review and approval and execution of a change order. Payment for the work herein authorized will not be made prior to the execution of a change order.