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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 12, 2018 Department <br />Name Roger T. Nawrot Division/Bureau <br />Engineering <br />BPW Date February 27, 2018 Phone Extension 5932 <br />Legal Attorney Name: Clara McDaniels <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing El <br />L_J Agreement <br />N Contract Ll Proposal Ll Addendum <br />F-1 Professional Services <br />El Resolution <br />R Bid Opening <br />E] Bid Award Req. to Advertise El Title Sheet <br />F-1 Quote Opening <br />0 Quote Award <br />El Change Order No. <br />F-1 C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />R Traffic Control: <br />Other: Contract Sum)lement No. 1 <br />Company or Vendor Name <br />INDOT <br />El Yes M No [J If Yes, Approved by <br />New Vendor <br />Purchasing <br />MBEANBE Contractor <br />F1 MBE [:] WBE <br />MBEANBE Contractor Requested <br />No 0 Yes Name of Company <br />Project Name <br />Olive Street Reconstruction <br />Project Number <br />114-064 (DES 1400637) <br />Funding Source <br />Local Roads and Streets <br />Account No. <br />251-0608-380.10-99 <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Supplement No. 1 is for a two-year time extension on the original <br />INDOT,-LPA Agreement. <br />F1 Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non-Dis,crim i nation, Non -Debarment, E-Verify, Iran, etc.) <br />g'e< r, ors;' On I "Y <br />Amount of F-1 increase <br />$ <br />El Decrease <br />$ <br />Previous Amount $ <br />Current Percent of Change: <br />% <br />New Amount $ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />F-1 F-1 <br />F-1 ❑ <br />