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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 13, 2019 Department Public Works <br />......... ....... . .... <br />Name Roger T. Nawrot <br />. ......... . <br />.... . . <br />Division/Bureau Engineering <br />BPW Date December 19, 2019 Phone Extension 5932 <br />........ . ........ <br />Required Prior to Submittal to Board <br />Legal F-1 <br />Attorney Name: <br />Controller F-1 <br />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 />............... ........................... Check the..��qjp(iate Item Type — Required for All Submissions <br />. . . . ............... . . ............. .. . . . . . . . .... . ............ . .. . .... :i—.-] <br />❑ Agreement <br />R <br />Contract F-1 Proposal 0 Addendum <br />El Professional Services <br />F-1 <br />Resolution <br />F1 <br />Bid Opening <br />Bid Award El Req. to Advertise Z Title Sheet <br />F] <br />Quote Opening <br />F1 <br />Quote Award <br />0 <br />Change Order No. <br />C/O & PCA No. E] PCA <br />F] Ease/Encroach. <br />Traffic Control: <br />Other: <br />rq_4_Information <br />Company or Vendor Name <br />HRP Construction Co, Inc. <br />................................................ <br />El Yes Z No E] If Yes, Approved by <br />New Vendor <br />Purchasina <br />—❑ ­ ­­­­­­ . ................ ............. <br />MBE/WBE Contractor <br />12MBE <br />[:] WB...................................E <br />MBE/WBE Contractor Requested <br />............. ............................................. . ................................................. . .. . <br />0 No 0 Yes Name of C m any . ........................ <br />Project Name <br />Miami Basin Valve Replacement <br />Project Number <br />... .................. <br />116-082D <br />Funding Source <br />LRSA Capital and South Side TIF <br />Account No. <br />------------- <br />251-0608-431.42-96 430-1050-460.42-01 <br />Amount <br />................... <br />.. ........ . . .... <br />Terms of Contract <br />Purpose/Description <br />F-1 Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Chan e qrqersmmOnl r <br />Amount of <br />F-1 increase <br />E] Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />1:1 <br />El <br />El <br />E] <br />El <br />El <br />................ . ...... <br />Disoersal After Ar)Droval <br />