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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />June 30. 2017 <br />er Nawrot <br />Department Public Works <br />BPW Date July 11, 2017 Phone Extension 5932 <br />J Agreement <br />U Contract U Proposal Lj Addendum <br />® Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ <br />Traffic Control <br />F,1 Other: Amendment No. 1 <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />MBEIVVBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />American Structurepoint, Inc. <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />F] MBE n WBE <br />❑ No ❑ Yes Name of Company <br />Additional South Bend Downtown Road, Traffic and Signal <br />Improvements Work <br />115-019 <br />TIF Bond <br />Amount $114,000.00 <br />Terms of Contract Not to Exceed <br />Purpose/Description Original nal agreement amount was $50,000.00 plus $114,000 <br />increases the total amount to $164,000. The increase is for the field <br />survey, design. and right-of-waV engineering for a left turn lane for <br />eastbound Sample Street at Main Street and the preparation of the <br />_quote package for the sidewalk along Main Street at the Chase <br />Tower. <br />X Required Contractor's Certification Form Attached (Non -Collusion, <br />Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required ForChan`ge Orders QnI „ <br />Y <br />Amount of ❑ increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ Roger Nawrot <br />