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Contract No:R -39540 <br />INDIANA Department of Transponation <br />Construction Change Order and Time Extension Summary <br />Review and App「ova=れformation <br />Required ApprovaI Authority <br />($ per Change Order) <br />(Days pe「 Cont「act) <br />VerbaI ApprovaI Required? <br />TotaI Change To-Date>5%? <br />ScopeIDesign Recommendation <br />Required? <br />Change Order No.: 003 <br />Page: 2 <br />AE:　　　　　DCE:　　　　SCE:　　　　★ DDCM:　　　* <br />(一LE$250K-)(-LE$750K-〉(-一LE$2M--)(〇一GT$2M一〇) <br />〈50SSdays) ( 100SSdays)(200SSDays) (GT20OSSdays) <br />Y/NIfY,by Date lssued <br />Y / N lf Y , Copy to Program Budget Manag' <br />Y / N lf Y, Referred to Project Manager(PM) <br />Date to PM <br />ApprovaI Authority Concurs with PM? Y I N If Y, Concurrence by <br />lf N,ResoIution: Approved <br />ResoIved by <br />Date Returned <br />Disapp「oved <br />Date <br />LPA Signatures Required?　　　　　Y I N If Y, Date to LPA <br />FHWA Signatures Required?　　　　Y / N lf Y,Date to FHWA <br />* Field Engineer Recommendation (Required for SCE or DDCM Approva!) <br />Fie!d Engineer <br />Comments: <br />Date <br />Date Petu「ned <br />Date Returned