Form No. 0/3 10U Dwg. No. HOLMES & NARVER Order No. Type F.S. No. Date: Title: Location INCORPORATED CHANGE ORDER ~Kind Job No. Sheet No. Detailed of Change Reason for Contract No. Project No. Description of Change of “Authority for Change TENTATIVE COST ESTIMATE AT JOBSITE... change: Affects Dwg. Nos. Proposed By: Date: Recommended By: Date: Approved By: Resident Manager, H & N Date: Approved By: Resident Engineer, AEC Date: REIMBURSEMENT AUTHORITY Approval of the above change in work or services, by the undersigned, constitutes reimbursement authority, covering the cost incurred in the performance of the work, as revised. Any change in the scope or character of the work necessitating adjustment of the total estimated contractual cost, and/or an adjustment of the Con- tractor's fixed-fee, will be authorized subsequently, by formal modification to the contract, in accordance with the provisions of Article XIII, Contract AT-(29-1) -507. Approved By: Contract Administrator Date: Approved By: Contracting Officer Date: Remarks: DISTRIBUTION A. BE. C. Los Angeles . 2 3 Engineering Div. Orig & 1 Fiscal 3 Construction Mgr. Service Operations Const. Off. Insp. Off. 6 1 1 1 - Cost Code L1-45