Customer's Name

Customer's Phone


You do hereby authorize Cantera Concrete Company to perform the work described herein:


Above additional work to be performed under same conditions as specified in original contract unless otherwise stipulated. Pricing to be completed by Cantera Concrete Company Corporate office for the below listed man hours, materials, and equipment. T&M will be based on the man hours, materials, and equipment listed below.

Please select one
Proceed on T&M (Authorized Signature)
Proceed after LS pricing (Authorized Signature)
Proceed with no cost (Authorized Signature)

We hereby agree to furnish labor, materials, and equipment in accordance with the contract documents and the above work description.

Authorized Signature
Resources Used
Man Hours
Employee classification (choose one)


Number of men
Hours (for each man)
Overtime Hours (for each man)

Total hours:


Equipment used

Hours that equipment was used

Material used

Date work completed
Contractor signature and date

I hereby agree that the man hours, materials, and equipment were used to complete the above work.

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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.