Form CEM-4901 "Change Order Input" - California

What Is Form CEM-4901?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-4901 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CHANGE ORDER INPUT
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
CEM-4901 (REV 05/2015)
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
CONSTRUCTION DEPT. USE ONLY
4
CONTRACT NO.
CCO NO.
SUPPL.
FUNCTION
OVERRIDE
1
3
8
9
13
14
15
C. C. O. DESCRIPTION
CARD TYPE
1
17
56
16
TIME
NET $ CHANGE
APPROVAL
-
-
-
.
CATEGORY
EXTENSION
THIS CCO
DATE
+ -
58
66
67
+ -
74
77
DAYS
PAYMENT METHOD
$ AMOUNT
CARD TYPE
CARD TYPE
2
4
NET $ AMOUNT BRIDGE WORK THIS CCO
EW
AC
FA
LS
UP
.
16
16
17
18
19
20
+ -
23
31
EW
AC
FA
LS
UP
.
.
+ -
+ -
18
26
EW
AC
FA
LS
UP
.
+ -
23
31
ITEM NUMBER
QUANTITY
ITEM NUMBER
QUANTITY
CARD TYPE
3
.
.
16
17
19
+ -
21
32
17
19
+ -
21
32
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
17
19
+ -
21
32
17
19
+ -
21
32
FEDERAL PARTICIPATION
FEDERAL SEGREGATION (IF MORE THAN ONE FUNDING SOURCE)
CARD TYPE
IF PARTICIPATING IN PART (S), BREAKDOWN COST AS FOLLOWS:
5
(INPUT TYPE AS P,M,N,R)
16
TYPE
COST
E = CCO to be funded as per contract
F = CCO to be funded as follows:
P = PARTICIPATING
17
28
29
.
18
19
27
M = NON-PARTICIPATING (MAINTENANCE)
FEDERAL FUNDING SOURCE
PERCENT
.
N = NON-PARTICIPATING
(OTHER THAN MAINTENANCE)
30
44
45
.
R = NON-PARTICIPATING
(REIMBURSEMENT BY OTHERS)
.
S = PARTICIPATING IN PART
18
19
27
30
44
45
IN CASE OF QUESTIONS CONTACT: NAME
BUSINESS PHONE
VERIFY
CEM-4901 REV 05/2015
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CHANGE ORDER INPUT
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
CEM-4901 (REV 05/2015)
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
CONSTRUCTION DEPT. USE ONLY
4
CONTRACT NO.
CCO NO.
SUPPL.
FUNCTION
OVERRIDE
1
3
8
9
13
14
15
C. C. O. DESCRIPTION
CARD TYPE
1
17
56
16
TIME
NET $ CHANGE
APPROVAL
-
-
-
.
CATEGORY
EXTENSION
THIS CCO
DATE
+ -
58
66
67
+ -
74
77
DAYS
PAYMENT METHOD
$ AMOUNT
CARD TYPE
CARD TYPE
2
4
NET $ AMOUNT BRIDGE WORK THIS CCO
EW
AC
FA
LS
UP
.
16
16
17
18
19
20
+ -
23
31
EW
AC
FA
LS
UP
.
.
+ -
+ -
18
26
EW
AC
FA
LS
UP
.
+ -
23
31
ITEM NUMBER
QUANTITY
ITEM NUMBER
QUANTITY
CARD TYPE
3
.
.
16
17
19
+ -
21
32
17
19
+ -
21
32
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
+ -
+ -
.
.
17
19
+ -
21
32
17
19
+ -
21
32
FEDERAL PARTICIPATION
FEDERAL SEGREGATION (IF MORE THAN ONE FUNDING SOURCE)
CARD TYPE
IF PARTICIPATING IN PART (S), BREAKDOWN COST AS FOLLOWS:
5
(INPUT TYPE AS P,M,N,R)
16
TYPE
COST
E = CCO to be funded as per contract
F = CCO to be funded as follows:
P = PARTICIPATING
17
28
29
.
18
19
27
M = NON-PARTICIPATING (MAINTENANCE)
FEDERAL FUNDING SOURCE
PERCENT
.
N = NON-PARTICIPATING
(OTHER THAN MAINTENANCE)
30
44
45
.
R = NON-PARTICIPATING
(REIMBURSEMENT BY OTHERS)
.
S = PARTICIPATING IN PART
18
19
27
30
44
45
IN CASE OF QUESTIONS CONTACT: NAME
BUSINESS PHONE
VERIFY
CEM-4901 REV 05/2015
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CHANGE ORDER INPUT
CEM-4901 (REV 05/2015)
HEADING
INSTRUCTIONS
Contract Number
Required
CCO Number
Enter CCO and Supplement Numbers.
CARD TYPE 1
CCO Description
CCO Description must be entered.
Net Money Change This CCO
Enter the amount of change. Enter zero if there is no net change. Indicate negative or
positive amount.
Approval Date
Enter the month, day, year and the Approval Date. The change order will not be filed until
it has been approved.
Time extension days
One of the following entries must be made:
1. Enter zero if there is no time extension.
2. Enter the number of Time Extension Days.
3. Enter "DEF" if consideration of a time extension has been deferred.
Category
Enter alpha-numeric code. Left justify if less than four characters.
CARD TYPE 2
EW or AC
Mark either the Extra Work or the Adjustment of Compensation boxes.
Payment Method
Mark one of the three Payment Method boxes, Force Account, Lump Sum or Unit price.
$ Amount
Enter the dollar amount of the change.
CARD TYPE 3
Item Number Quantity
Enter the contract item number and the quantity change for each item shown on the
change order.
CARD TYPE 4
Bridge Work
Enter the net amount of Bridge Work contained in this change order. Leave blank if zero.
CARD TYPE 5
Federal Participation
Enter FHWA Funding Participation determination on every change order.
Participating-in-Part funding
Indicate breakdown for Participating-in-Part funding.
Federal Segregation
If more than one funding source, mark if the CCO is to be funded as prescribed in contract
or show the percentage allotted to each Federal funding source.
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