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EXTRA WORK NO.: ________________       DATE: _________________________


FROM: ___________________________                                               ______________________

             (CONTRACTOR'S NAME)                                               (PROJECT)


            ___________________________                                 _____________________

           (CONTRACTOR'S ADDRESS)                                           (LOCATION)


           ___________________________                                  ________________________

          (CITY,    STATE,   ZIP)                                                         (JOB NUMBER)





TO:    __________________________

         (OWNER'S NAME)



           (OWNER'S ADDRESS)



        (CITY,   STATE,   ZIP)



       (TELEPHONE         FAX)





BY: ____________________________

BY: ____________________________


This EXTRA WORK ORDER includes all material, labor and equipment necessary to complete the following work: ____________________________________________


[ ] The work below to be paid for at actual cost of labor, materials and equipment plus _______ percent ( ___% ).


[ ] The work below to be completed for the sum of ______________________________ dollars ( $ __________ ).





_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ The work covered by this order shall be performed under the same Terms and Conditions as that included in the original contract unless stated otherwise above.


Submitted: _____________________          Customer Approval: __________________

                 (Contractor)                                                                   (Owner)


Date: __________________________                Date: _________________________


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