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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Name Alicia Czarnecki/Sue Ellen Doudrick Department Engineering <br />BPW Date 07/10/2018 Phone Extension5903 <br />Required Prior to Submittal to Board <br />Legal M Attorney Name Clara McDaniels <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 Michael Schmidt <br />Check the <br />H Agreement <br />Professional Services <br />Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />F-1 Ease/Encroach. <br />F-1 Other: <br />for All Submissions <br />I Proposal <br />[:1 Req. to Advertise <br />SIM <br />I Required Information <br />Company or Vendor Name Division 1: HRP Construction, Inc. <br />Addendum <br />El Title Sheet <br />New Vendor LJ Yes Ll No LJ If Yes, Approved by Purchasing <br />MBE/BE Contractor F-1 MBE F-1 WBE <br />MBENVBE Contractor Requested F-1 No F-1 Yes Name of Company <br />Mishawaka Avenue — Roto Rooter Jetter Removal and North Shore <br />Project Name Drive Improvements <br />Project Number 11 6,2R <br />Funding Source '8ewerezpft-at <br />Account No. <br />Amount 1: $45,451.00 / Division 2: $52,800,00 <br />'Terms of Contract <br />Purpose/Description Removal of a Ro,to-Rooter Jetter in the sewer main on Mishawaka <br />Avenue between Ironwood Drive and 23,d Street, and to replace <br />eight (8) catch basins and inlets on North Shore Drive <br />F-1 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non-Discrimnation, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of F-1 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 />F] F <br />E-] El <br />El F1 <br />