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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 07-03-2023 <br />Name: Jacob M. Klosinski Department of Public Works – Engineering Division <br />BPW Date: 07-11-2023 Phone Extension:9496 <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name Michael Schmidt <br />Dept. Attorney Attorney Name Michael Schmidt <br />Purchasing Mickey Lovy <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 <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 <br />Resolution naming Signatory for Indiana Finance Authority / State <br />Revolving Loan Fund (Drinking Water Projects) – Fellows Booster <br />Pumping Station and Lead Service Line Replacement <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Special Contract Provisions <br />Purpose/Description The Department of Public Works, Division of Engineering & Division of <br />Water Works requests the Board of Public Works accept a resolution <br />specifying Eric Horvath, Director of Public Works as the signatory for the <br />Indiana Finance Authority / Drinking Water State Revolving Fund projects. <br />For Change Orders Only <br />Amount of 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 />Time Extension Amount: <br />New Completion Date: