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Co巾胞瞭No:R -39540 <br />1NDIANA Dep種nment of T愉nsPo巾a髄on <br />Con鏡関劇lon Change O巾e細and Tjme Extonsさon Summ租「y <br />Revさew and Approv蜜l ln書orm軸ion <br />Required Approval Authorfty <br />($ per Change Order) <br />(Days per Co巾racI) <br />Verbai ApprovaI Requi鳩d? <br />TotaI Change To_D甜e>5%? <br />Scope佃esign Recom mendation <br />Re叩i鳩d? <br />Approval Authority Concurs with PM? <br />LPA Signatures Required? <br />FHWA §ignatu記S Required? <br />AE:DCE:　　　　SC宣: <br />Change OrdBr No。: OO4 <br />P負ge: 2 <br />* DDCM:　　　★ <br />("しE$25OK-〉(・しE?750K弓子-LE$2M○○)〈∴G丁$2M-〉 <br />(50SSdays ) ( 100SSdays) 〈 200SS Day§ 〉 (GT200 SSdays) <br />Y/N I†Y,by Date Issued <br />YI N If Y , Copy to Prog略m Budget Manay <br />Y I N lf Y, Refe「red to Project Manager(PM〉 <br />Date to PM <br />Y /剛f Y, Concurr飢ce by <br />If N,Resolution: Approv白d <br />Resoived by <br />Dale Retu「ned <br />Disapp調Ved <br />D ate <br />YIN llY, Dateto LPA <br />Y/ N II Y, Datoto FHWA <br />をFieId Engineer Recomm色ndation (Required fo「 SCE or DDCM Approval) <br />FieId Engineer <br />Com ments : <br />D割e <br />Date Retumed <br />D軸e Retumed