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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 16, 2017 <br />Name Jacob M. Klosinski Department Utilities Wastewater <br />BPW Date February 28, 2017 Phone Extension (574) 235-9496 <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® Carol Kurzhal <br />❑ <br />Agreement U <br />Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services ❑ <br />Resolution <br />❑ <br />Bid Opening ❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening ❑ <br />Quote Award <br />❑ <br />Change Order No. ❑ <br />C/O & PCA No. ® PCA <br />❑ <br />Ease/Encroach. ❑ <br />Traffic Control <br />❑ <br />Other: <br />Company or Vendor Name <br />Selge Construction Company, Inc. <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />I/N Tek and I/N Kote Sanitary Sewer Chemical Storage and Feed <br />Project Name <br />Facilities <br />Project Number <br />Funding Source <br />Utilities, Wastewater, Other Equipment <br />Account No. <br />641-0630-793-36-05 <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Utilities requests the Board of Public Works approval of Project <br />Completion Affidavit, Maintenance Bond, and Final Waiver of Lien <br />and release of retainage for the subiect proiect. All work is <br />complete. All deliverables have been received. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders <br />Only <br />Amount of ❑ Increase $ <br />❑ Decrease <br />$ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: % <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 />