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Contract No:B -44292 <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.: 004 <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 />0' N If Y, by S.Hauersperger . Date Issued_ 10/16/23 <br />Y /Of Y, Copy to Program Budget Manager <br />Y / NOf Y, Referred to Project Manager(PM) <br />Date to PM Date Returned <br />Approval Authority Concurs with PM? Y / N)f Y, Concurrence by <br />If N,Resolution: Approved <br />Resolved by <br />LPA Signatures Required? & N If Y, Date to LPA 10/16/23 <br />FHWA Signatures Required? Y Of Y, Date to FHWA_ <br />* Field Engineer Recommendation (Required for SCE or DDCM Approval) <br />Field Engineer Date <br />Comments: <br />Date <br />Disapproved <br />Date <br />Date Returned <br />Date Returned <br />