Change Order No 1 & PCA - Prairie Ave. Water Main Loop Proj No. 117-068 - HRP Construction, Inc.

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City of South Bend Department of Administration & Finance Change Order Request Form Multiple PO lines: Project POs: PO Number PO-0014485 Line Number Add Line 3 - Change Order No. 1; Change Order Amount $35,527.02 Original Dollar Amount $1,671,500.00 (Original Bid Total) New Dollar Amount (For liquidation request, enter $0)$1,707,027.02 Reason Code (if changed) Financial Dimensions (fund-dept- division-subdivision-main account) Account 1: 620-06-604-608-431002 --> Move $16,636.53 to PO-0014485 Line 3 Account 2: 622-06-604-620-442007 --> Move $18,829.50 to PO-0014485 Line 3 Account 3: 101-06-600-500-431000 --> Move $ 60.99 to PO-0014485 Line 3 Project Code (if applicable) Description of change (include budget impact) This change includes the finalization of PO-0000036 with HWC Engineering ($16,636.53), finalization of PO-0015001 with Christopher Burke Engineering LLC ($18,829.50), and a transfer of funds from Account 101-06-600-500-431000 to cover Change Order No. 1 for the subject project. This work included increased construction costs (net increase) due to the field relocation of a 12-inch water main along Prairie Avenue under Prairie Avenue pavement due to a utility conflict with NIPSCO gas. Engineering intends to issue Change Order No. 1 to Board of Public Works for approval at its 05/09/2023 BPW Meeting. This transfer will allow for Change Order No. 1 to be approved by the Board of Public Works along with closeout documents, payment of remaining invoices and retainge payment before the end of May 2023. Note: Closeout of this project is critical. Proof of closeout will allow the City to request a $500,000 reimbursement payment from the Pokagon Band of Potawatomi Indians and the Pokagon Gaming Commission in accordance with their Water and Sewer Extension Agreement for this water main extension project. APPROVED BY PROJECT ACCOUNTING TEAM (if applicable)(PAT member's name and date to be completed by PAT member) PO Number Line Number Original Dollar Amount New Dollar Amount (For liquidation request, enter $0) Changing the line amount: You can only change a line amount if it has NOT been invoiced against. • If the line has NOT been invoiced – reduce the line amount to equal what it should be. • If the line has been invoiced – cancel the delivery remainder and finalize the individual line, then add a new line for the amount that should be remaining. If you have changes to more than one line on the same PO, fill out a separate section for each line affected by the change order. For change orders on project-related POs, this form must be approved by the Project Accounting Team as described in Supplement 508. Supplement 508 Form - Change Order Request Form (1) - PO-0014485 1 of 4