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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/19/2019 <br />Department Public <br />Name Zach Hurst Works <br />BPW Date 3/26/2019 Phone Extension 3057 <br />uuui wa�man�; rrnrrswm�nu✓,� mmmuuummmmmmmmmm�mmmmmuuuuuuuuuuuuuuuummmuuuuuuuuuuuuuuuuuuuuuumwewmmmwmm�w w <br />.,,,.,.,..�......... .__._._._...... ... _ w.m...,,_.,..,.._............._......�.�,�,._........ _�� <br />R .. yir d Prior to Submittal to Board <br />�.... �........_.... _................... .-........ <br />BPW Attorney ® Attorney Name Sandi Kennedy <br />Dept. Attorney [:j Attorney Name <br />Purchasing El <br />Check the 1 bra a' t ITItem.Ty 1 <br />Professional Services Agreement Contract <br />Open Market Contract ❑ Amendment/Addendum <br />Bid Opening ❑ Bid Award <br />E] Quote Opening E] Quote Award <br />[❑ Proposal Opening C/O & PCA No. <br />Chg. Order, No. ❑ Traffic Control <br />E Other: <br />Information <br />All Submissions <br />Proposal <br />Special Purchase, QPA <br />❑ Req. to Advertise <br />❑ Reject Bids/Quotes <br />F-1 PCA <br />Resolution <br />Ease./Encroach <br />❑ Title Sheet <br />Company or Vendor Name <br />DLZ Indiana, LLC <br />Yes If Yes Approved by Purchasing �...._.. _ ......�_. ..�... <br />New Vendor <br />No <br />MBE/WBE Contractor <br />Q MBE Completed E-Verify Form Attached ® Nos <br />Project Name <br />Douglas Road Lift Station <br />Project Number <br />118-116 <br />Funding Source <br />...TIF............�..............������....................� �..�.. ����������................. ��.�............�.�.�.................�.�.�......_............._ <br />..Road <br />Douglas ............................................................... _��_�r�__.........................�............��� <br />Account No. <br />435-1050-460-31.02 <br />Amount <br />.-.-�m.._.--------------------- ...----- ...._���� <br />$108,800 <br />Terms of Contract <br />Purpose/Description ,p in erip r and right-of-way services for the re lacennucnt of the Douglas <br />Road limit station, as well as force maim relocations as part of St. Jose <br />p Ccn,'s <br />Douglas Road widct. enin _ro'e <br />_ .....................__._....... <br />._.._ _ .....�.W_ <br />For Cha�n�ge Orders Only <br />Amount of Increase $ ........... ... ... <br />Decrease $ <br />Previous Amount <br />$ <br />Increase <br />% <br />Current Percent of Change; <br />Decrease <br />New Amount <br />$ <br />Increase <br />_ <br />% <br />................................................... <br />Total Percent of Change: <br />Decrease <br />Time Extension Amount: <br />New Completion Date: <br />