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m� STATE AID FOR LOCAL TRANSPORTATION <br />CHANGE ORDER <br />Rev. February 2018 <br />SP/SAP(s)1 187-020-021 MN Project No.: Change Order No. 15 <br />**Group/ <br />funding <br />Category <br />Item No. <br />Description Unit <br />+ or — + or — <br />Unit Price Quantity Amount $ <br />7 <br />Install 4" Gate Valve with Box EACH <br />$ 1,575.20 1 $ 1,575.20 <br />2 <br />Install Kleen Break Mounting Systems EACH <br />$ 155.00 5 $ 775.00 <br />Prime Contractor Markup <br />10% $ 235.02 <br />Net Change this Change Order $ 2,585.22 <br />"Estimated amount, final quantities have not been completed <br />"Group/funding category Is required for federal aid projects <br />(X) Is NOT changed I () May be revised as provided in MnDOT Specification 1806 <br />( ) Is Increased by Working Days (X) Is Increased by Calendar Days <br />( ) Is Decreased by Working Days ( ) Is Decreased by Calendar Days <br />y ay- <br />Approved <br />rApproved by ' <br />Date: — 2 <br />Print Name: 1 tUty 66Z,4 f— <br />Approved by Contractor: 1� ��� Date: 5-r Ll -201`1 <br />Print Name: LEE 'Su N P AZ PU6 ►b &-t-.)T <br />Approved by Ramsey County: <br />Print Name: <br />Date: <br />Consultant Engineer: Date: S 2f <br />14 <br />Print Name: <br />DSAE Portion: The State of Minnesota is not a participant in this contract. Signature by the <br />District State Aid Engineer Is for FUNDING PURPOSES ONLY and for compliance with State <br />and Federal Aid Rules/Policy. Eligibility does not guarantee funds will be available. <br />This work is eligible for: _ Federal Funding _ State Aid Funding <br />District State Aid Engineer: <br />Page 2 of 2 <br />Local funds <br />Date: <br />