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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September IL) 2019 <br />Department <br />Name Jacob M. Klosinski Ert ineeriau l Utilities <br />BPW Date Se tember 24 2019 Phone Extension Ext. 9496 <br />iwi�auuwiui �mmmm��w uimwrm a� �unwd;�wrswrum�m000000mioumwmomomomomommwmo�m�marcrcemamwnuorere <br />Required Prior to Submittal to Board <br />......... _..._ ___............... w <br />BPW Attorney ® Attorney Name Clara McDaniels <br />Dept. Attorney F-1 Attorney Name <br />Purchasing <br />Check Pl? the A priat Item <br />Type <br />Professional Services Agr emet Contract <br />l u <br />Open Market Contract ❑ Amendment/Addendum <br />Bid Opening ❑ Bid Award <br />E] Quote Opening ❑ Quote Award <br />E] Proposal Opening [:] C/O & PCA No. <br />❑ Chg. Order, No. ❑ Traffic Control <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Information <br />All Submissions <br />LJ Proposal <br />F-1' Special Purchase, QPA <br />❑ Req. to Advertise <br />❑ Reject Bids/Quotes <br />® PCA <br />E] Resolution <br />E] Ease./Encroach <br />❑ Title Sheei <br />HRP Construction, <br />truction,Inc. (South ............nd Indiana) <br />ut Bet. <br />Yes If Yes Approved by Purchasing <br />® No <br />�❑ MBE Completed E-Verify Form Attached ❑❑ No <br />WBE <br />WWTP 117-0Headworks Influent Gates Improvements <br />.m._26 � �.�A,,,,.�....�. ................... <br />Wastewater Capital Account <br />642-0630-415-43-66 <br />The Division of En inecring and Division of Utilities request the Board of <br />Public Works- lW oral of 1't o'ect Com alctr tlLAf Cdavit for Project No. 1 I i <br />026 WW [ P Head mks Influent Gates Ian r�gments. All work is cornple <br />........ <br />Increase $ <br />Decrease $ ) <br />Increase �����% <br />Decrease _( % <br />Increase % <br />Total Percent of Change: Decrease ( %) <br />Time Extension Amount <br />New Completion Date:�� <br />