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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date October 16, 2018 <br />Name Jacob M. Klosinski <br />Department Utilities - Wastewater <br />BPW Date October 23, 2018 Phone Extension (574) 235-9496 <br />Required Prior to Submittal to Board <br />Legal <br />Attorney Name Clara McDaniels, Assistant City Attorney <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller <br />and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing Z <br />Kara Boyles, City Engineer <br />Check the Appropriate Item Type - Required forAll Submissions <br />F� Agreement <br />El Contract El Proposal El Addendum <br />Professional Services <br />F-1 Amendment <br />❑ <br />Bid Opening <br />El Bid Award Z Req,to Advertise Z Title Sheet <br />F] <br />Quote Opening <br />❑ Quote Award <br />Chg Order No. <br />❑ <br />C/O & PCA No. F-1 PCA <br />❑ Ease,/Encroach. <br />Traffic Control n Resolution <br />F-1 Other: <br />F-1 Claim <br />Company or Vendor Name <br />New Vendor <br />MBEWBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />uired Information <br />U Yes Ll If Yes, Approved by Purchasing <br />EJ No <br />❑ MBE WBE ❑Nos <br />Completed E-Verify Form Attached <br />Airport Annexation Area Sewer Extension <br />n/a <br />Utilities, Sewage WorksANastewater, Sewer Rehabilitation <br />642-01621-415-42-05 <br />Lump Sum / Unit Prices <br />The Division of Engineerinq is requesting ap_p roval of a Title <br />Sheet and Re nest to Advertise for the extension of sanita <br />sewers along the south side US 20 to accommodate <br />developments at the southwest quadrant of the US 31 US 20 <br />Interchange. 11 <br />For Change Orders Only <br />­ ­­ 111� �' M: 1, a 0 P <br />F] increase $ <br />Amount of F] Decrease $ <br />Previous Amount $ <br />Current Percent of Change- % <br />New Amount $ <br />Total Percent of Change: % <br />Time Extension: <br />Dispersal After Approval <br />Copy Original <br />Kara Boyles, City Engineer <br />F-1 Al Greek, Director of Utilities <br />F-1 Susan Zeeb, Director of lastewater Financial Services <br />