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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />March 20. 2017 <br />Department Utilities - Wastewater <br />BPW Date March 28, 2017 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 />Jacob M. Klosinski <br />Purchasing <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <br />® Carol Kurzhal <br />Contract <br />Resolution <br />Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control <br />Proposal <br />❑ Req. to Advertise <br />Company or Vendor Name DLZ Indiana, LLC <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 Farmington 14A Lift Station Rehabilitation <br />Project Number 117-027 <br />Funding Source Utilities, Wastewater Engineering <br />Account No. 641-0630-793-31-02 <br />Amount <br />Terms of Contract <br />Purpose/Description <br />ndum <br />❑ Title Sheet <br />engineering design plans for the Farmington 14A Lift Station <br />Included in the scope are Survey, Geotechnical Design Bidding <br />and Right-of-Wav services fees. <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc.) <br />Amount of ❑ Increase <br />❑ Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />® ❑ AI G <br />® ❑ Jaco <br />® ❑ Ca <br />Dispersal After Approval <br />Director of Utilities <br />amsK1, Assistant Gity Engineer <br />, Director of Financial Services <br />