CN-370000-CN210-T37CO2.pdf

Florida Department of Environmental Protection

TASK ASSIGNMENT CHANGE ORDER FORM

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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:

CN210 37 2 61292C

Ravine Gardens State Park Civic Center HVAC Improvements

CPH, Inc.

Christopher J. DeWaal, P.E. 920-241-4465 cdewaal@cphcorp.com

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

63 day time-only contract extension. Per the attached dated 12/10/2024.

$ 0.00 $ 33,743.56 $ 33,743.56 $ 0.00 $ 33,743.56 $ 33,743.56 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 33,743.56 $ 33,743.56

05/18/2022

12/31/2023

12/31/2024

03/03/2025

Tamika Bass

Uyles W. Keen Jr.

Ralph Perkins

Christopher J. DeWaal, P.E.

Michael W. Foster Jr., P.E.

$ 0.00