CONTRACT CHANGE ORDER FORM
Rev. General Contract Change Order 12.23 sam
CONTRACT INFORMATION Date:
Bid/Contract Number: Change Order Number:
Project Description:
Contractor: PO/Contract Number:
Original Contract Price:
Original Time Completion in Working Days:
CHANGE INFORMATION
Prior Contract Price
Change Order Amount
New Contract Price
Prior Time of Completion Days
Adjusted/Extension Time in Days
New Completion Time in Days
ENGINEERING USE ONLY:
Estimate Of Cost This Change Order Totals To Date
Contract Unit Prices
Extra Work
Agreed Prices
Eliminated Items
Total
% Change
Docusign Envelope ID: 8B5BA200-34FE-4898-B415-F18B49B630AC McDermott Soccer Field Iron Fencing Removal and Installation Project DASH Construction Company, Inc.
45 0
$172,400.00
01 45
$172,400.00
$163,780.00
11/24/2025
22401243
PW-24-139-CC
($8,620.00)
45 CONTRACT CHANGE ORDER FORM
Rev. General Contract Change Order 12.23 sam
INITIATING PARTY (Party responsible for initiating the change order request) Change Initiated By Agency Changes Requested By Contractor
REASON(S) FOR THE CHANGE ORDER
Detailed Justification (Required):
Execution of this change order by the Contractor constitutes a binding accord and satisfaction that fully satisfies, waives, and releases the Owner from all claims, demands, costs, and liabilities, in Contract, law or equity, arising out of or related to t he subject of the change order, whether known or unknown, Docusign Envelope ID: 8B5BA200-34FE-4898-B415-F18B49B630AC X
The contract retainage amount of $8.620.00 is being forfeited by the contractor due to excessive project completion delays due to their poor workmanship.
CONTRACT CHANGE ORDER FORM
Rev. General Contract Change Order 12.23 sam
including but not limited to direct and indirect costs and/or damages for delay, disruption, acceleration, loss of productivity, and stacking of trades, as well as any and all consequential damages.
Signature Page
Contractor: ___________________________________ Date: ____________
CITY OF FONTANA:
Project Manager: ______________________________ Date: ____________
Public Works Manager: __________________________ Date: ____________
Department Head: _____________________________ Date: ____________
Deputy City Manager: __________________________ Date: ____________ (Required if over $25,000)
City Manager: ________________________________ Date: ____________ (Required Over $50,000)
Review of Analysis:
Purchasing Office: ____________________________ Date: ____________
Finance Department: ___________________________ Date: ____________
Docusign Envelope ID: 8B5BA200-34FE-4898-B415-F18B49B630AC 11/24/2025
11/25/2025
11/25/2025
11/26/2025
11/26/2025
12/02/2025
1 Dan West
From: Ryan Rosebeary
Sent: Monday, August 25, 2025 4:15 PM
To: [email protected]
Cc: Sid Lambert; Dan West
Subject: McDermott Fencing
Thank you for meeƟng with us today. We appreciate your efforts to correct the work that was previously done incorrectly. With your new partnership with United Iron Works, we would like to move forward with them performing the necessary repairs. Before any work begins, we would like to schedule an on-site meeƟng with the staff who will be performing the repairs to review our expectaƟons. Following that, we would also like to receive a Ɵmeline for the compleƟon of the work. We are available on September 2nd at 8:00 a.m. to meet at McDermoƩ Soccer for the iniƟal walkthrough if that works for you. Also, it is clear that this project went well past the expected finish date; therefore, the City shall retain the final retainage of $8,620. Thank you for your Ɵme and we look forward to hearing from you.
Ryan Rosebeary
Parks and Landscape Supervisor • Public Works
City of Fontana • 16489 Orange Way • Fontana, CA 92335
[email protected] • Office: (909) 428-8811
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Docusign Envelope ID: 8B5BA200-34FE-4898-B415-F18B49B630AC Certificate Of Completion
Envelope Id: 8B5BA200-34FE-4898-B415-F18B49B630AC Status: Completed Subject: Contract Change Order for Approval from Dan West Source Envelope:
Document Pages: 4 Signatures: 6 Envelope Originator:
Certificate Pages: 6 Initials: 0 Purchasing Office
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-08:00) Pacific Time (US & Canada)
8353 Sierra Avenue
Fontana, CA 92335
[email protected]
IP Address: 192.146.186.122
Record Tracking
Status: Original
11/24/2025 | 02:35 PM
Holder: Purchasing Office
[email protected]
Location: DocuSign
Signer Events Signature Timestamp
Dan West
[email protected]
Security Level:
DocuSign.email
ID: 1
11/24/2025 | 02:35 PM
Completed
Using IP Address: 192.146.186.122
Sent: 11/24/2025 | 02:35 PM
Viewed: 11/24/2025 | 02:35 PM
Signed: 11/24/2025 | 02:42 PM
Electronic Record and Signature Disclosure:
Accepted: 10/9/2024 | 03:28 PM
ID: 30ce6951-d964-4d85-bc8a-4fa2a9cda523
Ticha Loera
[email protected]
Pumpman LLC
Security Level: Email, Account Authentication
(None)
Completed
Using IP Address: 192.146.186.96
Sent: 11/24/2025 | 02:42 PM
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Electronic Record and Signature Disclosure:
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Dan West
[email protected]
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Sent: 11/24/2025 | 03:12 PM
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Signed: 11/24/2025 | 03:13 PM
Electronic Record and Signature Disclosure:
Accepted: 11/24/2025 | 03:13 PM
ID: eb48e83d-6cc5-4253-84b0-ca8f68789c32
DASH Construction Company, Inc.
[email protected]
President
DASH CONSTRUCTIPN COMPANY INC.
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Signed: 11/25/2025 | 01:59 PM
Electronic Record and Signature Disclosure:
Accepted: 11/24/2025 | 03:57 PM
ID: 8ae22bf1-0234-4a27-8ec6-fd4478148df8
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Dan West
[email protected]
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Using IP Address: 2600:387:15:3f10::1
Signed using mobile
Sent: 11/25/2025 | 01:59 PM
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Signed: 11/25/2025 | 08:27 PM
Electronic Record and Signature Disclosure:
Accepted: 11/25/2025 | 08:26 PM
ID: c2c35922-a38f-4096-b440-6d3af191c811
Gia Kim
[email protected]
Public Works Director/City Engineer
City of Fontana
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Sent: 11/25/2025 | 08:27 PM
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Signed: 11/26/2025 | 09:21 AM
Electronic Record and Signature Disclosure:
Accepted: 11/26/2025 | 09:20 AM
ID: 080d6119-4cac-4f4a-b0e5-b97866382138
Sid Lambert
[email protected]
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Sent: 11/26/2025 | 09:21 AM
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Electronic Record and Signature Disclosure:
Not Offered via Docusign
Jessica Brown
[email protected]
Chief Financial Officer
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Signed using mobile
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Signed: 12/2/2025 | 07:56 AM
Electronic Record and Signature Disclosure:
Accepted: 12/2/2025 | 07:55 AM
ID: 1c5a11a0-2913-488e-9ee5-ad115994cc6a
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
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Intermediary Delivery Events Status Timestamp
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Purchasing
[email protected]
Purchasing Office
Paragon Partners Consultants, Inc.
Security Level: Email, Account Authentication
(None)
Using IP Address: 192.146.186.96
Sent: 11/24/2025 | 03:01 PM
Viewed: 11/24/2025 | 03:12 PM
Electronic Record and Signature Disclosure:
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Carbon Copy Events Status Timestamp
Kathy Kasinger
[email protected]
Records Coordinator
Security Level: Email, Account Authentication
(None)
Sent: 12/2/2025 | 07:56 AM
Electronic Record and Signature Disclosure:
Accepted: 12/1/2025 | 01:11 PM
ID: d241f8ee-2a74-470c-9845-a9af8b91fcac
Laurie Miller
[email protected]
Security Level: Email, Account Authentication
(None)
Sent: 12/2/2025 | 07:56 AM
Electronic Record and Signature Disclosure:
Accepted: 4/3/2025 | 04:34 PM
ID: 4b1f8c38-592c-4aa8-b4b1-0ed5964022ac
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 11/24/2025 | 02:35 PM
Certified Delivered Security Checked 12/2/2025 | 07:55 AM Signing Complete Security Checked 12/2/2025 | 07:56 AM
Completed Security Checked 12/2/2025 | 07:56 AM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure
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Electronic Record and Signature Disclosure created on: 2/2/2017 | 06:54 AM Parties agreed to: Dan West, Ticha Loera, Dan West, DASH Construction Company, Inc., Dan West, Gia Kim, Jessica Brown, Kathy Kasinger, Laurie Miller How to contact City of Fontana:
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