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Contract No:R -39540 <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 />Y / N If Y, by Date Issued <br />Y / N If Y, Copy to Program Budget Manager <br />Y / N If Y, Referred to Project Manager(PM) <br />Date to PM <br />Approval Authority Concurs with PM? Y / N If Y, Concurrence by <br />If N,Resolution: Approved <br />LPA Signatures Required? <br />Resolved by <br />Y / N If Y, Date to LPA <br />Date Returned <br />Date <br />Disapproved_ <br />Date <br />Date Retumed <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 <br />Comments: <br />Date <br />