Project Completion Affidavit - Erskine Clubhouse Renovation Project No 116-108 - Ziolkowski Construction

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BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 19 m ... �....w Name ITo Vi11 Department: Engineering BPW Date 08/27/2019 Phone Extension 5920 i� w wr�rsruummmmummran� er�u�aenermmrc�!rrcnamxm rwr wuma^u� ._. _ RuiredPrior.to Submittal to Board BPW Attorney ❑ Attorney Name Dept. Attorney E) Attorney Name ............. ....... �w_�ww��..._..................................__........ a Purchasing ....... Check the Ault fate Item Ty1cc�l F Professional Services Agreement E] Contract El Open Market Contract ❑ Amendment/Addendum El Bid Opening ❑ Bid Award ❑ Quote Opening ❑ Quote Award ❑ Proposal Opening C/O & PCA No. El Chg. Order, No. Traffic Control F� Other: Company or Vendor Name New Vendor MBE/WBE Contractor Project Name Project Number Funding Source Account No. Amount Terms of Contract Purpose/Description (bi- All Submissions ❑ Proposal [❑ Special Purchase, QPA EJ Req. to Advertise ❑ Title Sheet ❑ Reject Bids/Quotes ® PCA Resolution Ease./Encroach ZiolkowsYeki Construction, Inc. _._...._................_ _ m...._..... s [:] If Yes, Approved by Purchasing ® No ❑ MBE Completed E-Verify Form Attached ❑ WBE Erskine Clubhouse Renovation 116-108 S.S...TIF-..-..-....................................._.....................w 430.1050.460.42.02 / 405.1101.452.42.02................... $1„101,342.00 r iect Closeout ❑ Yes ❑ No __ _... ........ ............ __-.— __ . . _ For Charg Orders Oh y Amount of El Increase $ ❑ Decrease$....................................m.m.m.............._....._...._...._..............................�...... Previous Amount $ Current Percent of Change: New Amount Total Percent of Change: Time Extension Amount: New Completion Date: Increase % Decrease 0 ........_..0. Increase Increase ............ � Decrease ( %