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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />November 30, 2016 <br />Roger Nawrot <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date December 13, 2016 Phone Extension 6932 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <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 ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ 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. 5 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />F1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Increase <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Chance: <br />Copy Original <br />® ❑ <br />Required Information <br />Indiana Department of Transportation <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑Yes Name of Company <br />Olive Street and Sample Street Reconstruction <br />113-002 <br />Major Moves <br />412-04 ,40542.03 y/ 1 - ay°!. y15 q2 .a3 <br />$11,752.00 <br />Federal 80%, City 10% & County 10% <br />This change order is for changing the temporary concrete barrier <br />wall on the new Sample Street westbound bridge to a metal <br />barrier wall so that the number of holes in the new bridge deck is <br />reduced from 300 to 60. City's share of the change order is <br />$1,175.20. <br />L Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />:ouired For Chance Orders Only <br />Nawrot <br />Fisher Associates <br />