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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 6/5/2018 <br />Name Sue Ellen Doudrick <br />Department <br />Division/Bureau <br />Engineering <br />BPW Date 6/12/2018 Phone Extension 9157 <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 El <br />H Agreement Amendment <br />F-1 Professional Services <br />] Bid Opening <br />F-1 Quote Opening <br />Z Change Order No. 1 <br />❑ Ease/Encroach. <br />Other: <br />U Contract <br />F1 Resolution <br />El Bid Award <br />0 Quote Award <br />El C/O & PCA No. <br />F1 Traffic Control: <br />E] Req. to Advertise E] Title Sheet <br />NEW, <br />Company or Vendor Name Selge Construction <br />El Yes Z No E] If Yes, Approved by <br />New Vendor Purchasing <br />MBEIWBE Contractor <br />MBENVBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No., <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Ll MBE " WBE <br />R No El Yes Name of Company <br />Old Clay Utilities Sewer Lining <br />117-087 <br />Utility <br />641-0621-792.63-35 <br />Increase of $23,060 (for a total PO amount of $228,805) <br />Unit Prices <br />Change Order #1 — A) Change in contract time due to change in <br />scope and required easement acquisition for sewer installation. <br />B) Increase of project cost due to elimination of sewer lining <br />therefore increasing sewer pipe diameter being directionally <br />drilled. <br />F-1 Required Contractor's Certification Forms Attached (Non - <br />Collusion, Neon -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Previous Amount $205,745 <br />Current Percent of Change: 11,21% <br />New Amount __$__226,805 <br />Total Percent of Change: 11.21% <br />Copy Original <br />F1 1:1 <br />El R <br />