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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date April 29,2019 <br />Department Public Works <br />..................... ­­ � <br />Name Roger Nawrot Division/Bureau Engineering <br />BPW Date May 14, 2019 Phone Extension 5932 <br />IIMEMPMMMMMIIIIIIIIIIillilliw���ui�w�wuiwn mmomommumpp5mmmmmmimimmmiiiiiiiiimimlilillwwmwwMMMPPPME <br />iredPrior to Subm ..ittal to Board <br />............ <br />Legal Attorney Name: <br />Controller El 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 <br />LJ Agreement <br />El Professional Services <br />r-1 Bid Opening <br />E:1 Quote Opening <br />Z Change Order No. 7 <br />Ease/Encroach, <br />Other: <br />Company or Vendor Name <br />?roprLiat�q Item <br />F-1 Contract <br />F1 Resolution <br />F-1 Bid Award <br />Quote Award <br />❑C/O & PCA No. <br />F-1 Traffic Control: <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 />for All Submissions <br />Proposal <br />F] Req. to Advertise <br />ired Information <br />F1 PCA <br />Indiana Department of Transportation <br />Addendum <br />F1 Title Sheet <br />Yes LJ No,,,_,,,, mm If Yes, App oved byPur�ci <br />1:1 MBE [] WBE... <br />. ............... El No 0 Yes Name of Company <br />Boland Trail R-36881 <br />..... — ----- <br />113-047 <br />Federal 80% and City 20% <br />This change order is for correcting the number of days entitled to <br />the Contractor in Change Order #5 for the accidental discovery <br />and the non -construction season durin the winter. <br />9 ........... <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />... . ............ ......... <br />aquired For Chanqe Orders Only <br />Amount of ❑ Increase $ <br />Decrease $ <br />Previous Amount 1,351,234.17 <br />Current Percent of Change. <br />New Amount 1,351,234.17 <br />Total Percent of Phagge: 16.10% <br />Disoeri�­[—Afte—r <br />Copy Original <br />z r-1 ­R_9ger Nawrot <br />F] E] <br />11 El <br />M <br />