- Change Notification-

Change Notification
PO N°: CONTRACT DESCRIPTION: CONTRACT N°:

ORIGINATOR: CONTRACTOR: DATE: CN N°: REV:

Short Description:

DISCIPLINE CHANGE CAUSE OF CHANGE

EARTH MOVEMENT ELECTRICAL ENGINEERING CHANGES
CIVIL INSTRUMENTATION SCOPE CHANGES
STRUCTURAL COMMISSIONING SITE CONDITION
PIPING PAINTING CLIENT INSTRUCTION
MECHANICAL OTHER OTHER
DESCRIPTION OF CHANGE: (Include references – Use additional pages if required)

Cost and Schedule Impact

YES NO YES NO
This Change has Cost Impact This Change has Schedule Impact

Currency: USD

LABOR $ NO. OF DAYS:

MATERIALS $

All the support documentation

EQUIPMENT $
is attached:

OTHER $ will be sent within five days:

TOTAL VALUE
OF CHANGE $

Originator´s Signature Date

REPLY:
Form No. FR-CADM-000-001-10 - Rev Date: 124-Jan-2014 Contract Administration
File: FR-CADM-000-001-10 1/2
 - Change Notification-

Contracts Manager Date

CONTRACTOR REPRESENTATIVE ACCEPTANCE SIGNATURE: (Required when issued by PETMIN)

THIS CHANGE NOTIFICATION REPRESENTS FINAL ADJUSTMENT FOR ANY AND ALL AMOUNTS OR IMPACTS OF ANY KIND DUE
OR TO BECOME DUE CONTRACTOR FOR CHANGE REFERRED TO HEREIN. CONTRACTOR FURTHER RELEASES ALL OTHER CLAIMS,
IF ANY, FOR ADDITIONAL COMPENSATION UNDER THIS CONTRACT, INCLUDING WITHOUT LIMITATION ANY RIGHTS
CONTRACTOR MAY HAVE PRIOR TO THE DATE OF THIS CHANGE NOTIFICATION. UNLESS OTHERWISE EXPRESSLY PROVIDED
HEREIN, THE TIME OF COMPLETION AND ALL OTHER TERMS AND CONDITIONS OF THE CONSTRUCTION AGREEMENT REMAIN
UNCHANGED

Signature Name Date

PETMIN REPRESENTATIVE ACCEPTANCE SIGNATURE:

Signature Name Date

PETMIN - APPROVALS

CONTROLS MANAGER: DATE

SUBCONTRACTS MANAGER: DATE

CONSTRUCTION MANAGER: DATE

SITE MANAGER: DATE

Form No. FR-CADM-000-001-10 - Rev Date: 124-Jan-2014 Contract Administration

File: FR-CADM-000-001-10 2/2