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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/12/2021 <br />Name Kyle Silveus <br />Department Public Works <br />Engineering Division <br />BPW Date 11/23/21 Phone Extension 9083 <br /> <br />Required Prior to Submittal to Board Legal Attorney Name _ Clara McDaniels_________________ <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type – Required for All Submissions <br /> Agreement Contract Proposal Addendum <br /> Professional Services Resolution <br /> Bid Opening Bid Award Req. to Advertise Title Sheet <br /> Quote Opening Quote Award <br /> Change Order No. C/O & PCA No. PCA <br /> Ease/Encroach. Traffic Control <br /> Other: INDOT-LPA <br />Required Information <br />Company or Vendor Name Indiana Department of Transportation <br />New Vendor Yes No If Yes, Approved by Purchasing <br />MBE/WBE Contractor MBE WBE <br />MBE/WBE Contractor <br />Requested No Yes Name of Company <br />Project Name Coal Line Trail Phase II <br />Project Number ENG: 115-064 DES No.: 1401811 <br />Funding Source Riverwest TIF <br />Account No. 324-444000 <br />Amount N/A <br />Terms of Contract <br />Purpose/Description Amendment of INDOT/LPA contract to extend the terms and <br />schedule <br /> Required Contractor’s Certification Form Attached (Non- <br />Collusion, Non-Discrimination, Non-Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of <br /> <br />Increase <br />Decrease <br />$ <br />$ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br /> <br /> <br /> <br />