NEW JERSEY DEPARTMENT OF TRANSPORTATION
AUTHORIZATION FOR UTILITY FIELD CHANGES	
PROJECT:	     	SECTION:	     	
LOCATION:	     	FEDERAL PROJECT NO:	     	
UTILITY 	     	
UTILITY AGREEMENT NO:	     	TASK ORDER NO:	     	
OR MASTER AGREEMENT NO:	     	CHANGE ORDER NO:	     	
DESCRIPTION OF CHANGE IN UTILITY WORK (I.E., WORK NOT COVERED BY EXISTING UTILITY AGREEMENT
NECESSARY TO PROGRESS THE STATE’S CONSTRUCTION PROJECT AND THE REASON FOR THE CHANGE:	
     	
     	
     	
     	
     	
     	
UTILITY ESTIMATE TO NEAREST $1,000:	     	  INCREASE
  DECREASE	
THE CHANGE IN UTILITY WORK AND COST ESTIMATE HAVE BEEN DISCUSSED WITH AND APPROVED BY:	
			
			     		     		
	UTILITY REPRESENTATIVE (Signature)		(Print)		(Date)		
			     		     		
	RESIDENT ENGINEER (Signature)		(Print)		(Date)		
			     		     		
	FHWA AREA ENGINEER (Signature)		(Print)		(Date)		
	(Major Changes on Full Oversight Projects Only)		     		     		
							
	N.J.D.O.T. PROJECT MANAGER (Signature)		(Print)		(Date)		

C:	Utility Coordination Unit (PMO Office)
	Regional Construction Engineer
	FHWA on Full Oversight Project
	Project Manager (Distribute Copies)