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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01 /30/2023 <br />Name Jitin Kam <br />Department: PW <br />BPW Date 02/14/2023 <br />Phone Extension 5835 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney X <br />Attorney Name <br />Michael Schmidt <br />Dept. Attorney ❑ <br />Attorney Name <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type -- Re aired far All Submissions <br />❑ Professional Services Agreement ® Contract <br />❑ Proposal <br />❑ Open Market Contract <br />❑ Amendment/Addendum ❑ Special Purchase, QPA <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheei <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Reject Bids/Quotes <br />❑ Proposal Opening <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ Chg. Order, No. <br />❑ Traffic Control <br />❑ Resolution <br />❑ Other: <br />Ease./Encroach <br />Required Information <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 />NIPSCO <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />X No <br />❑ MBE Completed E-Verify Form Attached ❑❑ No <br />❑ <br />WBE <br />NIPSCO/South Bend Cross Bore Safety Initiative Agreement <br />Purpose/Description The project involves NIPSCO televisingthe he City sewer to verify and identi <br />any damage from cross boring ryas lines. Any damages to sewer piping <br />identified by NIPSCO will be repaired at their expense. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <br />Increase % <br />Current Percent of Change: Decrease <br />New Amount $ <br />Increase <br />Total Percent of Change: Decrease <br />Time Extension Amount: <br />New Completion Date: <br />