18-0116_SIEMENS INDUSTRY, INC._Contract_Exhibit AEXHIBIT “A”
CHANGE ORDER FORM
City of San Juan Capistrano
Contract Change Order #
Project: Change Order No.:
Orig. Contract Amt.:
$
Days
Contract No.:
Contractor: Prev. Appvd. Changes: $ Days
Owner: City of San Juan Capistrano This Change: $ Days
Revised Contract Amt.: $ Days
This Change Order covers changes to the subject contract as described herein. The Contractor
shall construct, furnish equipment and materials, and perform all work as necessary or required
to complete the Change Order items for a lump sum price agreed upon between the Contractor
and City of San Juan Capistrano, otherwise referred to as Owner.
Item
No.
Description of Changes
Increase/
(Decrease)
in Contract
Amount
Contract
Time
Extension,
Days
1
2
Totals
$
This Contract Change Order consists of 2 pages and any exhibits attached to this Contract Change Order shall not be part of the
Contract Change Order unless specifically initialed by or on behalf of both the Contractor and the City of San Juan Capistrano.
Contract Change Order # Page 1 of 2
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
(949) 493-1171
The amount of the contract will be increased by the sum of $ and the contract time shall be
extended by working days. The undersigned Contractor approves the foregoing Change Order # as
to the changes, if any, in the contract price specified for each item including any and all supervision
costs and other miscellaneous costs relating to the change in work, and as to the extension of time
allowed, if any, for completion of the entire work on account of said Change Order #. The Contractor
agrees to furnish all labor and materials and perform all other necessary work, inclusive of the directly
or indirectly related to the approved time extension, required to complete the Change order items.
This document will become a supplement of the contract and all provisions will apply hereto. It is
understood that the Change Order shall be effective when approved by the Owner.
Contractor accepts the terms and conditions stated above as full and final settlement of any and all
claims arising out of or related to the subject of this Change Order and acknowledges that the
compensation (time and cost) set forth herein comprises the total compensation due for the work or
change defined in the Change Order, including all impact on any unchanged work. By signing this
Change Order, the Contractor acknowledges and agrees that the stipulated compensation includes
payment for all Work contained in the Change Order, plus all payment for any acceleration or
interruption of schedules, extended overhead costs, delay, and all impact or cumulative impact on all
Work under this Contract. The signing of this Change Order acknowledges full mutual accord and
satisfaction for the change and that the stated time and/or cost constitute the total equitable
adjustment owed the Contractor as a result of the change. The Contractor hereby releases and
agrees to waive all rights, without exception or reservation of any kind whatsoever, to file any further
claim or request for equitable adjustment of any type, for any reasonably foreseeable cause that shall
arise out of, or as a result of, this Change Order and/or its impact on the remainder of the Work under
the Contract.
Accepted:
(Signature) Contractor’s Authorized Representative Date
Recommended:
(Signature) [**INSERT NAME, TITLE**] Date
Approved:
(Signature) [**INSERT NAME, TITLE**] Date
Item
No.
Justification for Change(s)
1
2
This Contract Change Order consists of 2 pages and any exhibits attached to this Contract Change Order shall not be part of the
Contract Change Order unless specifically initialed by or on behalf of both the Contractor and the City of San Juan Capistrano.
Contract Change Order # Page 2 of 2