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10. rT 12, 43. 4 CHECK LIST {For Sanction of Deviation Statement) Name of the work Details of Original A/A Details of Agreement (Agreement No. & Amount) Amount of Deviation & Reasons thereof (Attach Deviation Statement, Original work programme and Revised ‘work programme) Whether deviation amount exceeds 10% more than the original agreement value. If exceeds more than 10% reasoning with technical report may be attached. Whether revised A/A is necessary / accorded? if so a copy of the A/A order. Permission from the competent ‘authority to go ahed with the execution may be furnished, Is the deviation due to change of design / site? If so a copy of the approval order for such changes may be furnished. Whether recommended by {a) Executive Engineer (0) Superintending Engineer Relative position of tenders at deviated quantity (whether the position has been altered or not) Whether EOT has been granted up to the required extent? If so 2 copy there of may be furnished. If the delay is due to change of design / site, The circumstances for such changes may be stated {Permission letter may be furnished) If the delay is due to heavy untimely rain fail, whether 2 certificate is furnished from the competent authority showing the details of rain “Revised estimate for the work "Construction and maintenance to MV76 to Bhejingiwada road in the district of Malkangiri under RCPLWEA. Program*. (OR2ORCPL 12 PART: 1)) under the road connectivity project of Left Wing. ‘Administrative approval has been accorded originally. Rs 2481.72 Letter No.7854 Dt.18-05-2018 of Govt. Works department, Odisha. 16/RCPLWEA/2018-19/EE Rs.221315886.00 (0.12% Less} s.114.00 Attached, Deviation statement attached separately. Na, NA. Yes, A/A copy Attached. Na, Change of design Yes Does not arise Provisional £.0.T up to 31.03.2020 No Yes, Attached fall during the period of hindrance. 15. Reasons as to why {() Compensation will not be levied on : Not Applicable the contractor {ii} benefit of price escalation will not Not Applicable be curtailed / disallowed 16. Whether any £.0.T was granted : No previously, If so with benefit of price escalation of without the same. 17. Whether any Audit Para / Draft Para: No (CRAG Para Is pending against the work. {Attach copy of Audit Para / Draft Para CBAG Para, if any)

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