Form 0/S 277 Dwg. No. Order No. Type F.S. No. Date: Title: Location HOLMES & NARVER INCORPORATED EXTRAORDINARY MAINTENANCE WORKORDER Kind Detailed of Change Description of Change Contract No. Project No. Job Ne. Sheet No. of Authority for Change | 4 Reason for Change: TENTATIVE COST ESTIMATE AT JOBSITE...... 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 Contractor'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 Remarks: DISTRIBUTION A. E. C, Los Angeles 2 3 Engineering Div. Orig & 1 Fiscal 3 11-46 Date: Construction Mgr. 6 Const. Off. Insp. Off. L 1 Service Operations 1 Cost Code