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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/1/23 <br />Name Gemma Stanton Department DPW <br />BPW Date l l /l 4/23 Phone Extension 9083 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney <br />❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item I <br />Professional Services Agreement ❑ Contract <br />❑ Open Market Contract <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Proposal Opening <br />® Chg. Order, No. 4 <br />I-1 Other: <br />❑ Amendment/Addendum <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />Information <br />All Submissions <br />U Proposal <br />❑ Special Purchase, QPA <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />Ease./Encroach <br />Company or Vendor Name INDOT (Contractor is Milestone) <br />New Vendor ❑ Yes❑ If Yes, Approved by Purchasing <br />❑ No <br />MBE/WBE Contractor ❑❑ ❑ <br />MBE Completed E-Verify Form Attached ❑ Yes <br />No <br />Project Name Coal Line Trail Phase IIB <br />Project Number 122-035 <br />Funding Source TIF — River West <br />Account No. 324-444000 <br />Amount $7,381.52 <br />Terms of Contract <br />Purpose/Description Change order #4 for charges incurred during drinking fountain installation <br />For Change Orders Only <br />Amount of ❑ Increase $ 7,381.52 <br />❑ Decrease ($ ) <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />$ 3,501,153.99 (previous change orders); $3,450,217.13 (original) <br />Increase 0.214% <br />Decrease % <br />$ 3,508,535.51 <br />Increase 1.690% <br />Decrease ( % <br />New Completion Date: <br />