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Contract No:R -38064 Change Order No.: 005 <br />INDIANA Department of Transportation Page: 2 <br />Construction Change Order and Time Extension Summary <br />Review and Approval Information <br />Required Approval Authority AE:________ DCE:________ SCE:________* DDCM:_______* <br />($ per Change Order) (- LE $ 250K-) (- LE $ 750K - ) ( -- LE $ 2 M -- ) ( -- GT $ 2 M -- ) <br />(Days per Contract) ( 50 SS days ) ( 100 SS days ) ( 200 SS Days ) ( GT 200 SS days) <br />Verbal Approval Required?Y / N If Y, by_____________ Date Issued___________ <br />Total Change To-Date>5%?Y / N If Y , Copy to Program Budget Manager_________________ <br />Scope/Design Recommendation <br />Required? <br />Y / N If Y, Referred to Project Manager(PM) __________________ <br />Date to PM__________ Date Returned___________ <br />Approval Authority Concurs with PM? Y / N If Y, Concurrence by_______________ Date___________ <br />If N,Resolution: Approved __________ Disapproved ___________ <br />Resolved by_________________________ Date__________ <br />LPA Signatures Required?Y / N If Y, Date to LPA _____________ Date Returned _________ <br />FHWA Signatures Required? Y / N If Y, Date to FHWA____________ Date Returned_________ <br />* Field Engineer Recommendation (Required for SCE or DDCM Approval) <br />Field Engineer _________________________Date _____________ <br />Comments: ____________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________