CN-370000-CN208-T9CO2.pdf.crdownload

Florida Department of Environmental Protection

TASK ASSIGNMENT CHANGE ORDER FORM

(Revised 9-26-2018) Page 1 of 1

Required Signatures: Adobe Signature

FDEP Contract No.: Task Assignment No.: Change Order No.: Project No.:

Project Location: Project Name:

Consultant Name:

Consultant Representative: Phone: Email:

FDEP Contract Manager: Phone: Email:

Description and Justification of Change:

Change in Task Amount:

Item Reimbursement Fixed Fee Total

Original Task Amount:

Task amount including all previous Change Orders:

Net increase/decrease in task amount for this Change Order:

Total Amounts with all Change Orders:

Change in Task Time:

Original Task Execution Date:

Original Task End Date:

Present Task End Date:

Net Change in Days:

New Task End Date:

Approval Signatures:

Budget Representative, FDEP Signature Date

Project Manager, FDEP Signature Date

Contract Manager, FDEP Signature Date

Consultant Signature Date

Contract Authority, FDEP Signature Date

Project # Grant # Org Code Cat/Year Fund Module Object Code EO Amount

29 Digit FLAIR Code: Total:

CN208 09 02 61311C

Fort Zachary Taylor Overflow Parking

Calvin Giordano & Associates

James Messick, PE 954-921-7781 jmessick&cgasolutions.com

Ralph Perkins 850-245-2460 ralph.perkins@floridadep.gov

Time only addition to allow completion of contracted tasks (bidding support and construction administration) per the attached request dated 8/15/22.

$ 14,915.00 $ 14,915.00 $ 7,745.00 $ 59,758.92 $ 67,503.92

$ 0.00 $ 0.00 $ 0.00 $ 7,745.00 $ 59,758.92 $ 67,503.92

10/09/2020

9/23/21

10/23/22

4/1/2023

Tamika Bass Tamika Bass Digitally signed by Tamika Bass Date: 2022.09.21 08:49:28 -04'00'

Theresa Carron T.Carron Digitally signed by T.Carron Date: 2022.08.16 13:03:03 -04'00'

Ralph Perkins Ralph M Perkins Digitally signed by Ralph M Perkins Date: 2022.09.21 09:51:58 -04'00'

James Messick, PE Jenna Martinetti Digitally signed by Jenna Martinetti Date: 2022.09.23 16:28:36 -04'00'

Michael W. Foster Jr., P.E. Michael W. Foster Jr., P.E.

Digitally signed by Michael W.

Foster Jr., P.E.

Date: 2022.09.26 11:17:57 -04'00'

$ 0.00