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Construction Program Management and Inspection Guide

Appendix G (continued)

DOT Logo CALIFORNIA DIVISION
RECORD OF PRIOR APPROVAL FOR MAJOR CONTRACT CHANGE ORDER
PROJECT NO.CCO NO.CONTRACT NO.DIST-CO-RTE-PM
REQUESTED BY: ___ CALTRANS HQ
___ RE/DISTRICT
DATE:
PROPOSED CHANGE:
REASON FOR CHANGE:
AS DISCUSSED IN FIELD (REPORT NO. __________)
TIME EXTENSIONS

check box NONE _____ DAYS check box DEFERRED
ACTIVITY ON CRITICAL PATH AFFECTED BY CCO (IF TIME EXTENSION INVOLVED)
ESTIMATE OF COST:

$_____ check box INCREASE check box DECREASE
CCO: METHOD OF PAYMENT
check box CONTRACT ITEMS check box ADJUSTMENT OF COMPENSATION
check box AGREED PRICE check box EXTRA WORK AT FORCE ACCOUNT
THE WORK COVERED BY THE PROPOSED REVISION AS DESCRIBED ABOVE IS APPROVED SUBJECT TO SUBMISSION OF SUPPORTING DOCUMENTATION INCLUDING COST EVALUATION ANDJUSTIFICATION OF TIME EXTENTIONS.

OTHER CONDITIONS:

PRIOR APPROVAL TO PROCEED GRANTED BY: DATE OF AUTHORIZATION:

Form FHWA CA-358 ©Converted to Word 1/01 (Copy to CT)

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Updated: 11/25/2013
Federal Highway Administration | 1200 New Jersey Avenue, SE | Washington, DC 20590 | 202-366-4000