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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />May 10, 2018 <br />Department <br />Public Works <br />Name <br />Roger Nawrot <br />Division/Bureau <br />Engineering <br />BPW Date <br />May 22, 2018 <br />Phone Extension <br />5932 <br />❑ Agreement <br />❑ Contract ❑ Proposal jJ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />® Change Order No. 1 <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control: <br />F] Other: <br />Company or Vendor Name Indiana Department of Transportation <br />New Vendor <br />MBEIWBE Contractor <br />MBEIWBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />U Yes LJ No If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No 0 Yes Name of Company <br />SRTS Monroe Primary and Studebaker Elementary R-39513 <br />116-039 <br />-$12,549.50 (deduct) <br />Federal 80% and City 20% <br />This change order is for changing of the street patching at the <br />handicap ramps and adding borrow material to fill the holes left <br />by the tree removal. City share of the change order is $2,315.00 <br />deduction. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, 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 />Dispersal After Approval <br />Copy Original - <br />® ❑ Roger Nawrot <br />❑ ❑ <br />❑ ❑ <br />