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Contract No:R -39513 <br />Change Order No.: 004 <br />INDIANA <br />Department of Transportation Page: 2 <br />Construction Change <br />Order and Time Extension Summary <br />Review and Approval Information <br />Required Approval Authority <br />AE:, DCE: SCE: * DDCM: <br />($ per Change Order) <br />(- LE $ 250K-) (- LE $ 750K -) (-- LE $ 2 M --) (-- GT $ 2 M -- ) <br />(Days per Contract) <br />( 50 SS days) (100 SS days ) ( 200 SS Days) ( GT 200 SS days) <br />Verbal Approval Required? <br />Y®If Y, by Date Issued <br />Total Change To-Date>5%? <br />Y 0 Y, Copy to Program Budget Manager <br />Scope/Design Recommendation <br />Y / ) Y, Referred to Project Manager(PM) <br />Required? <br />Date to PM-- Date Returned <br />Approval Authority Concurs with PM? <br />Y / N If Y, Concurrence by Date <br />If N,Resolution: Approved Disapproved <br />Resolved icy Date <br />,LPA Signatures Required? <br />YQ N If Y, Date to LPA Date Returned <br />FHWA Signatures Required? <br />Y ,9If Y, Date to FHWA Date Returned <br />* Field Engineer Recommendation (Required for SCE or DDCM Approval) <br />Field Engineer Date <br />Comments: <br />