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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date Department Public Works <br />Name Rebecca Maenhout Division/Bureau Engineering <br />BPW Date 07/11/2023 Phone Extension 5996 <br />Required Prior to Submittal to Board <br />Legal Attorney Name: Michael Schmidt <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 Michael Schmidt <br />Check the Appropriate Item Type – Required for All Submissions <br /> Agreement Amendment 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: <br />Required Information <br />Company or Vendor Name INDOT B-44292 <br />New Vendor <br /> Yes No If Yes, Approved by <br />Purchasing <br />MBE/WBE Contractor MBE WBE <br />MBE/WBE Contractor Requested No Yes Name of Company <br />Project Name B-44292 Coal Line Trail Phase IIB <br />Project Number 122-035 <br />Funding Source <br />Account No. <br />Amount $0.00 <br />Terms of Contract <br />Purpose/Description <br /> Change Order 1 covers the material related change for the structural concrete using E5. <br />There is no cost associated with this change nor is there a time extension. <br /> Required Contractor’s Certification Forms Attached (Non- <br />Collusion, Non-Discrimination, Non-Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of Increase <br />Decrease <br />$ <br />$ <br />Previous Amount $ 3,450,217.13 <br />Current Percent of Change: <br />New Amount $ 3,450,217.13 <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy Original <br />1X <br />06/27/2023