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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 20, 2016 <br />Name Jacob M. Klosinski <br />Department Division of Utilities <br />BPW Date December 22 2016 Phone Extension (574) 235-9496 <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® Carol Kurzhal <br />❑ Agreement ❑ Contract ❑ Proposal L] Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />® Change Order No. 002 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />F— Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Thieneman Construction, Inc. <br />Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE I I WBE <br />WWTP - Grit and Screenings Improvements <br />114-075 <br />Environmental Services Treatment and Disposal Equipment Account <br />642-0630-415-43-66 <br />$ Change Order, see below <br />Division of Utilities recommends the approval of Change Order No. 2 for <br />the subject project. Refer to Inter -Office Memorandum and enclosures for <br />description of changes and additional days due to lead time on equipment. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of N Increase <br />❑ Decrease <br />Previous Amount <br />'.: <br />Current Percent of Change: +2.12% <br />New Amount $ 1,172,917.50 <br />Total Percent of Change: +2.35% <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 />