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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 12-05-2022 <br />Name: Jacob M. Klosinski Department of Public Works – Engineering Division <br />BPW Date: 12-13-2022 Phone Extension: 9496 <br /> <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name Michael Schmidt <br />Dept. Attorney Attorney Name Michael Schmidt <br /> <br />Purchasing Mickey Lovy / Erich Haley <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 Selge Construction Company, Inc. (V-00001471) <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 CSO 18 Backwater Valve Replacement <br />Project Number 120-017 (PO-0012466) <br />Funding Source Sewage Works Operations – Other Contractual Services <br />Account No. 641-06-605-514-439001 <br />Amount <br />Terms of Contract <br />Special Contract Provisions <br />Purpose/Description The Division of Engineering and Division of Utilities (Wastewater) requests <br />the approval of a Project Completion Affidavit for Selge Construction <br />Company, Inc. for the subject project at the 12/13/2022 BPW Meeting. Work <br />was completed in early November. All documentation is complete. <br />For Change Orders Only <br />Amount of <br /> <br />Increase <br />Decrease <br />$ <br />($ ) <br />Previous Amount $ <br />Current Percent of Change: <br />Increase <br />Decrease <br />% <br />(%) <br /> <br />New Amount $ <br />Total Percent of Change: <br />Increase <br />Decrease <br />% <br />(%) <br /> <br />Time Extension Amount: <br />New Completion Date: <br />