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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 06-02-2022 <br />Name: Jacob M. Klosinski Department of Public Works – Engineering Division <br />BPW Date: 06-14-2022 Phone Extension: 9496 <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name Clara McDaniels <br />Dept. Attorney Attorney Name Clara McDaniels <br />Purchasing Michael Schmidt <br />Check the Appropriate Item Type – Required for All Submissions <br /> Professional Services Agreement Contract Proposal <br /> Open Market Contract Amendment/Addendum Special Purchase, QPA <br /> Bid Opening Bid Award Req. to Advertise Title Sheet <br /> Quote Opening Quote Award Reject Bids/Quotes <br /> Proposal Opening C/O & PCA No. PCA <br /> Chg. Order, No. Traffic Control Resolution <br /> Other: Ease./Encroach <br />Required Information <br />Company or Vendor Name <br />New Vendor Yes If Yes, Approved by Purchasing <br /> No <br />MBE/WBE Contractor MBE <br />WBE Completed E-Verify Form Attached Yes <br /> No <br />Project Name South Well Field Backwash Line Relocation <br />Project Number 117-059C / PROJ# 00000082 <br />Funding Source 430-10-102-121-444000 TIF – Southside Development #1 <br />Account No. PR # 00017366 <br />Amount <br />Terms of Contract <br />Special Contract Provisions <br />Purpose/Description Title Sheet and Request to Advertise for the subject project. The South Well <br />Field Backwash Line will be relocated to discharge at a manhole at W. <br />Chippewa Avenue. <br />For Change Orders Only <br />Amount of Increase <br />Decrease <br />$ <br />($ ) <br />Previous Amount $ <br />Current Percent of Change: <br />Increase <br />Decrease <br />% <br />( %) <br /> New Amount $ <br />Total Percent of Change: <br />Increase <br />Decrease <br />% <br />( %) <br />Time Extension Amount: <br />New Completion Date: <br />June 14, 2022