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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date October 16, 2017 <br />Name Jacob M. Klosinski <br />Department Utilities -- Wastewater <br />BPW Date October 24, 2017 Phone Extension (574) 235-9496 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name Catherine Fanello <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />® Carol Kurzhal <br />U Agreement <br />U Contract Ll Proposal L] Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ® Req. to Advertise ® Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />n Other: <br />Company or Vendor Name <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor <br />❑ MBE ❑ WBE <br />MBEIWBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Wastewater Treatment Plant Headworks Influent Gate <br />Project Name <br />Improvements <br />Project Number <br />117-026 <br />Funding Source <br />Utilities, Wastewater Capital <br />Account No. <br />642-0630-415-43-66 <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Request approval of Title Sheet and Request to Advertise for <br />Project No. 117-026 Wastewater Treatment Plant Headworks <br />Influent Gate Improvements <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of <br />Previous Amount <br />Increase $ <br />❑ Decrease $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Al Greek, Director of Utilities <br />0 ❑ Jacob M. Klosinski, Assistant City Engineer <br />® ❑ Carol Kurzhal, Director of Financial Services, Environmental Services <br />