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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/22/17 <br />Name Roger Nawrot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />® Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ <br />Traffic Control: <br />ri <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />Indiana <br />of Transportation <br />❑ Yes ❑ No L If Yes, Approved by <br />Purchasing <br />M11: ■ <br />MBEIWBE Contractor Requested <br />❑ No ❑j Yes Name of Company <br />Project Name <br />2017 Community Crossings Grant <br />Project Number <br />117-071 <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Matching up to $670,000 <br />Purpose/Description <br />This grant is used for the Ironwood Drive Improvements north of <br />Rockne Drive to SR 23. <br />Note- Must be signed with blue ink! <br />❑ Required Contractor's Certification Forms Attaches[ (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ❑ increase <br />❑ Decrease <br />$ <br />$ <br />Previous Amount $ <br />Current Percent of Change: <br />% <br />New Amount $ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Roger Nawrot <br />❑ ® Marcia Blansett, LPA Program Director, INDOT LaPorte District, PO Box 429, <br />❑ ❑ 315 East Boyd Bvld., LaPorte, IN 46352/46350 <br />