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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 06/27/2023 <br />Name Rebecca Maenhout <br />Department <br />Division/Bureau <br />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 />❑X Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />I-1 Other: <br />Required Information <br />Company or Vendor Name INDOT B-44292 <br />❑ Yes ® No ❑ If Yes, Approved by <br />New Vendor 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 116 <br />Project Number 122-035 <br />Funding Source <br />Account No. <br />Amount $0.00 <br />Terms of Contract Change Order 1 covers the material related change for the structural concrete using E5. <br />Purpose/Description 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 />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 />❑ ❑ <br />