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Cont「act No:R輸39540 <br />INDIANA Department of Transportation <br />Construction Change Orde「 and Time Extension Summary <br />Review and Approva1 1nformation <br />Required App「OVai Authority <br />($ pe「 Change O巾e「) <br />(Days pe「 Contract) <br />Ve巾al Approval Required? <br />Total Change To-Date>5%? <br />Scope/Design Recommendation <br />Req面℃d? <br />App「OVal Authority Concu「s with PM? <br />LPA Signatu「es Requi「ed? <br />FHVVA Signatures Required? <br />Change Orde「 No.: 005 <br />Page: 2 <br />AE:　　　　　DCE:　　　　　SCE:　　　　* DDCM:　　　　農 <br />(-LE$250K-)(-LE$750K-)(輸しE$2M-)(-GT$2M--) <br />( 50 SS days) ( 100 SS days) ( 200 SS Days) ( GT200 SS days) <br />Y/N lfY,by Date lssued <br />Y / N lfY , Copy to Program Budget Managl <br />Y / N lfY, Refe「red to PrQject Manager(PM) <br />Date to PM <br />Y/ N lfY, Concumence by <br />lf N,Resolution: Approved <br />ResoIved by <br />Date Retumed <br />Date <br />Disapproved <br />Date <br />Y/N lfY, DatetoLPA <br />Y/NIfY, <br />Date Retumed <br />Date to FHVVA Date Retumed <br />青FieId Enginee「 Recommendation (Requi「ed fo「 SCE o「 DDCM ApprovaI) <br />Field Enginee「 <br />Comments: <br />Date