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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 04/07/2020 <br />Department Public <br />Name Zach Hurst Works <br />BPW Date 04/14/2020 Phone Extension 3057 <br />Required Prior to Submittal to Board <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required. for All Submissions <br />❑ Professional Services Agreement ❑ Contract ❑ Proposal <br />❑ Open Market Contract ® Amendment/Addendum ❑ Special Purchase, QPA <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes <br />❑ Proposal Opening ❑ C/O & PCA No. ❑ PCA <br />❑ Chg. Order, No. ❑ Traffic Control ❑ Resolution <br />M Other: Interlocal Agreement n Ease./Encroach <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Information <br />INDOT — LaPorte District <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />❑❑ MBE Completed E-Verify Form Attached ❑ Yes <br />No <br />Cleveland Rd./Brick Rd. Pavement Improvements <br />119-045 <br />RWDA TIF <br />324-1050-460-42.03 <br />$1,248,475.08 <br />Interlocal Cooperative Agreement between local and state govt. <br />See attached memo. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <br />Increase <br />Current Percent of Change: Decrease <br />New Amount $ <br />Increase <br />Total Percent of Change: Decrease <br />Time Extension Amount: <br />New Completion Date: <br />