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Contract No:R -36881 <br />INDIANA Department of Transportation <br />Construction Change Order and Time Extension Summary <br />Review and Approval Information <br />Required Approval Authority <br />($ per Change Order) <br />(Days per Contract) <br />Verbal Approval Required? <br />Total Change To-Date>5%? <br />Scope/Design Recommendation <br />Required? <br />Change Order No.: 004 <br />Page: 2 <br />AE: DCE: SCE: * DDCM: <br />(-LE$250K-){-LE$750K-)(--LE$2M--)(--GT$2M--) <br />( 50 SS days ) ( 100 SS days) ( 200 SS Days) ( GT 200 SS days) <br />Y I N If Y, by Date Issued <br />Y 1 N If Y, Copy to Program Budget Manager <br />Y 1 N If Y, Referred to Project Manager(PM) <br />Date to PM Date Returned <br />Approval Authority Concurs with PM? Y 1 N If Y, Concurrence by Date <br />If N,Resolution: Approved Disapproved <br />Resolved by Date <br />LPA Signatures Required? Y 1 N If Y, Date to LPA Date Returned <br />FHWA Signatures Required? Y 1 N If Y, Date to FHWA Date Returned <br />* Field Engineer Recommendation (Required for SCE or DDCM Approval) <br />Field Engineer Date <br />Comments: <br />