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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 3, 2017 <br />Name Jacob M. Klosinski Department Div. of Utilities (ORF) <br />BPW Date February 14 2017 Phone Extension (574) 235-9496 <br />Legal ® <br />Attorney Name <br />Michael Schmidt, Assistant City Attorney <br />Controller ® <br />Controller review is <br />required for all Contracts $5,000.00 or more and <br />greater than one year <br />in length per the City Purchasing Policy <br />Purchasing ® <br />Carol Kurzhal <br />Check the Appropriate <br />Item Type <br />— Required <br />for All Submissions <br />❑ Agreement <br />❑ <br />Contract <br />❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />❑ <br />Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />® Change Order No. 1 <br />❑ <br />C/O & PCA No. <br />® PCA <br />❑ Ease/Encroach. <br />❑ <br />Traffic Control <br />n Other: <br />Company or Vendor Name Alfa Laval <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name WWTP Belt Filter Press #3 Rehabilitation <br />Project Number 116-051 <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Previous Amount <br />641 <br />Utilities requests the approval of Change Order No. 1 (deduct of <br />$5 000 unused allowance) and the Project Completion Affidavit for <br />the WWTP Belt Filter Press #3 Rehabilitation project. All work is <br />complete. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment, E-Verifv, Iran, etc.) <br />Increase $ <br />Decrease $ 5,000.0 <br />10J, <br />Current Percent of Change: -2.60% <br />New Amount $ 187,665.00 <br />Total Percent of Change: -2.60% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Al Greek, Director of Utilities <br />® ❑ Jacob M. Klosinski, Assistant City Engineer <br />® ❑ Carol Kurzhal, Director of Financial Services, Environmental Services <br />