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["FP-COC 03/2013",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"page 1 of 2"]
[null,null,"THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK"]
[null,null,"Office of Facilities Planning, 89 Washington Avenue, Room 1060 Education Building Annex, Albany, NY 12234"]
[null,null,"Tel. (518) 474-3906"]
[null,null,"Tel. (518) 474-3906"]
[null,null,"www.p12.nysed.gov/facplan/"]
[]
[null,null,null,"CHANGE  ORDER  CERTIFICATION"]
[null,null,null,null,"Must be attached to back of Change Order"]
[]
[]
[null,"Instructions:","This CERTIFICATION is required for all change orders submitted to SED",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Change Order Number:"]
[null,null,"Fill out all three parts completely."]
[]
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["Part One - General Information"]
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[null,"Provide separate Change Orders for each Project Number"]
[]
["SED Project Number"]
[null,null,null,"District BEDS Code",null,null,null,null,null,null,null,"Building Identification Number",null,null,null,"Project number      "]
["District & Building Name"]
[]
["Type of Project"]
["Project Description"]
[]
[]
["Architect / Engineer firm"]
[null,null,null,null,"name",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"address"]
["Contact Person"]
[null,null,null,null,"name & title",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"phone number & e-mail"]
[]
["Construction Manager firm"]
[null,null,null,null,"name",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"address"]
["Contact Person"]
[null,null,null,null,"name & title",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"phone number & e-mail"]
[]
["District Contact Person"]
[null,null,null,null,"name & title",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"phone number & e-mail"]
[]
[]
[]
["Part Two"]
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["Provide the following information for each individual item in the change order:"]
[null,null,"  (Number each item if there is more than one and provide additional sheets as necessary.)"]
[]
["A.","Requested By (Who initiated the change request)"]
["B.","Relationship to Project Scope (How is this change related to the original project scope)"]
["C.","Basis of Need (Describe why the change is needed)"]
["D.","Description of Work (Provide a detailed description of the work or services provided in the change order.  Provide text, a drawing or both as necessary to demonstrate code compliance and the individual cost of each item.)"]
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["FP-COC 03/2013",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"page 2 of 2"]
[null,null,null,"CHANGE  ORDER  CERTIFICATION"]
[]
[]
["Part Three"]
[]
[]
[1,"Change order requirements:"]
[]
[null,"a","The scope of the change order must relate to the project scope previously approved."]
[null,"a","Dollar amounts applied from allowances toward costs associated with the changes must be provided."]
[]
[null,"a","If the cost of this change order is not within the approved amount as currently established on the SA-4, please provide a Form FP-FI, Request for Revision of Financial Information, with documentation showing the additional authorization of funds."]
[]
[]
[null,"a","Each change order shall be signed by the president of the board of education, the architect/engineer, and the contractor."]
[]
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[]
[]
[]
[2,"Certification of the Superintendent of Schools (District Superintendent if a BOCES project)"]
[]
[null,"The following statements are true and correct to the best of my knowledge and belief:"]
[]
[null," =  The revised total cost is within the authorized appropriation for this project.  "]
[null," =  Where any work of this change order requires a type or kind of work that is not included in the original contract documents, the school district's attorney has been contacted to assure conformance with the Opinion of the State Comptroller No. 60-505."]
[]
[]
[]
[]
[null,"Date",null,null,null,"Signature and printed name of the School Superintendent or District Superintendent if a BOCES project"]
[]
[]
[]
[]
[]
[3,"Certification of the Architect or Engineer"]
[]
[null,"The following statements are true and correct to the best of my knowledge and belief:"]
[]
[null," =  Work required by this change order is in accordance with applicable sections of the approved contract documents."]
[]
[null," =  Any plan, sketch, or attachment referenced In this change order is included herein."]
[null," =  Work required by this change order is in accordance with applicable provisions of the NYS Uniform Fire Prevention and Building Code, State Education Department's building standards, and NYS Department of Labor's Code Rule 56."]
[]
[]
[null," =  Work required by  this change order was designed by an architect or engineer who is currently licensed by the State of New York."]
[]
[null," =  Work required by this change order that involves asbestos-containing building material (ACBM) was designed by an architect or engineer who is currently licensed by the State of New York and who is appropriately certified as an asbestos designer by the NYS Department of Labor at the time he/she designed the asbestos-related project."]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"Architectural / Engineering Firm Name"]
[]
[]
[]
[null,"Date",null,null,null,null,"Signature and printed name of the Architect or Engineer"]