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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 2, 2016 <br />Name Jacob M. Klosinski Department Div. of Env. Services <br />BPW Date September 13, 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 $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® Carol Kurzhal <br />Check the Appropriate Item Tvpe — Reauired for All Submissions <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <br />Company or Vendor Name <br />New <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />❑ Contract <br />❑ Resolution <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />River Construction <br />❑ Req. to Advertise <br />Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE n WBE <br />❑ Title Sheet <br />WWTP - Digester No. 2 Upgrade and Digester Gas Cleaning <br />111-029 <br />2012 Sewer Bond <br />15-42-06 <br />$ 5,930,037.00 (Final Project Cost) <br />Lump Sum <br />Request the Board of Public Works approval of the Project Completion <br />Affidavit. All work is complete. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ A] Greek <br />® <br />❑ Jacob M. Klosinski <br />® <br />❑ Carol Kurzhal <br />