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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date August 1, 2016 <br />Name Jacob M. Klosinski Department Division of Utilities <br />BPW Date August 9, 2016 Phone Extension (574) 235-9496 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® Carol Kurzhal <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />® Change Order No. 004 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Thieneman Construction, Inc. <br />J Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE ❑ WBE <br />WWTP - Secondary Treatment Improvements <br />114-053 <br />2012 Sewer Bond <br />661-0630-415-42-06 <br />Sum <br />Division of Utilities recommends the approval of Change Order No. 4. <br />Refer to Inter -Office Memorandum and enclosures for description of <br />changes (additions). <br />❑ Required Contractor's Certification Form Attached (Non - <br />Required For Change Orders Only <br />Amount of ® Increase $ 606,776.00 <br />❑ Decrease $ <br />Previous Amount $ 11,986,221.75 <br />Current Percent of Change: +5.11% <br />New Amount $ 12,592,997.75 <br />Total Percent of Change: +5.96% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Al Greek, Division Director of Utilities <br />® ❑ Jacob M. Klosinski, Assistant City Engineer <br />® ❑ Carol Kurzhal, Director of Financial Services, Environmental Services <br />