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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date March 19, 2018 <br />Name Jacob M. Klosinski Department <br />Utilities - Wastewater <br />BPW Date March 27, 2018 Phone Extension 574 235-9496 <br />U Agreement <br />U Contract <br />LJ Proposal U Addendum <br />❑ Professional Services <br />® Amendment <br />❑ <br />Bid Opening <br />❑ <br />Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Chg Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ <br />Ease./Encroach. <br />❑ Traffic Control <br />❑ Resolution <br />n Other: <br />I-1 Claim <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />A&Z Engineering <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />® No <br />MBE ❑ Ye <br />WBE Completed E-Verify Form Attached . ®Nos <br />Airport Annexation Area Sanitary Sewer Extension <br />117-108 (a.k.a. Chocolate Park Sewer Main Extension) <br />2018 TIF River West — Airport; Engineering_PSA <br />324-1050-460-31-02 (TIF); 101-0608-431-31 -06 <br />$53,550.00 <br />Lump Sum <br />Amendment to existing Professional Services Agreement. Scope <br />of work includes sanitarV sewer design, eotechnical exploration, <br />& utility location as required to extend sanitary sewer from US 20 <br />& US 31 Interchanae to US 201 Poppy Road Pump Station. <br />Amount of ❑ Increase $ <br />❑ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />1 <br />Dispersal After Approval <br />Copy <br />Kara Boyles, City Engineer <br />Daniel Buckenmeyer, Director of Econ. Resources & Bus. Development <br />Jacob M. Klosinski, Assistant City Engineer ......... ...... <br />......... ........ <br />Original <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />