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Contract No:R -39514 <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.: 001 <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 / N If Y, by Date Issued,---- <br />Y / N If Y, Copy to Program Budget Manager, rv, <br />Y / N If Y, Referred to Project Manager(PM) <br />Date to PM <br />Approval Authority Concurs with PM? Y / N If Y, Concurrence by <br />If N,Resolution: Approved <br />Date Returned <br />Resolvedby_......-...........-_.._.._.. ........ <br />._ <br />LPA Signatures Required? Y / N If Y, Date to LPA _ <br />FHWA Signatures Required? Y / N If Y, Date to FHWA <br />* Field Engineer Recommendation (Required for SCE or DDCM Approval) <br />Field Engineer wy mm mmm _ w wwwwww Date <br />Comments: <br />Date <br />Disapproved <br />Date <br />Date Returned <br />Date Returned <br />