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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 7/18/2023 <br />Name: Charlie Brach Department of Public Works — Engineering Division <br />BPW Date: 7/25/2023 Phone Extension: 9246 <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name Michael Schmidt <br />Dept. Attorney ❑ Attorney Name <br />Purchasing <br />❑� <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 />I-1 Other: 71 Ease./Encroach <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 />Special Contract Provisions <br />Purpose/Description <br />Amount of ❑ <br />El <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Information <br />4502 South Michigan Street LLC <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />F] MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Mike's Carwash Sanitary Sewer Easement <br />DP22-006 <br />N/A <br />PR4k9-# N/A <br />N/A <br />N/A <br />N/A <br />The easement approved for the sanitary sewer at Mike's Carwash on <br />3/14/2023 will need to be rescinded and replaced with the attached easement <br />document. There is a pipeline easement that conflicts with the sanitary sewer <br />easement, so the language needed to be modified to address that. <br />For Change Orders <br />Increase <br />Decrease <br />Increase % <br />Decrease ( %) <br />Increase % <br />Total Percent of Change: Decrease ( %) <br />Time Extension Amount: <br />New Completion Date: <br />