MnDOT TP-2460-0112-16
STATE OF MINNESOTA DEPARTMENT OF TRANSPORTATION Contract No.
CHANGE ORDER NO.
Page 1 of 1
CONTRACTOR: /FEDERAL PROJECT NO.
/ STATE PROJECT NO.ADDRESS: / LOCATION OF WORK
This Contract uses MnDOT Standard Specifications for Construction Choose an item.
In accordance with the terms of this Contract, you are hereby authorized and instructed to perform the Work as altered by the following provisions.
On dd/mm/yyyy, a Ford tandem axle dump truck, Mn. license ______was being operated at intersection of TH 24 and Bauer St. dumping fill material without an operational backup alarm or a signal person while having an obstructed view to the rear. The driver and Contractor’s Safety Rep were warned the previous day of the same violation. Action was promised but the same violation occurred the following day.
In accordance with Specification 1706 and special provision S-ZZ.z, MnDOT is hereby assessing a monetary deduction in the amount of $500 for the incident dated dd/mm/yyyy.
Upon notification, dd/mm/yyyy, that this was the second violation in two days and that a monetary deduction was being assessed, the Contractor immediately removed the truck from the project until the backup alarm could be replaced.
Total amount of monetary deduction = $500.00
Signature / DateProject Engineer/Supervisor
Contractor Authorized Representative
*Assistant District Engineer
**Local Agency
***Consultant Contract Administrator
* Required for Work Orders that exceed $25,000.00
** Required if work funded wholly or in part by a Local Agency
*** Recommendation for Approval