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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 6/22/23 Department Public Works <br />Name Rebecca Maenhout Division/Bureau Engineering <br />BPW Date 06/27/2023 Phone Extension 5996 <br />Required Prior to Submittal to Board <br />Legal Attorney Name: Michael Schmidt <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 Michael Schmidt <br />Check the Appropriate Item Type – Required for All Submissions <br /> Agreement Amendment Contract Proposal Addendum <br /> Professional Services Resolution <br /> Bid Opening Bid Award Req. to Advertise Title Sheet <br /> Quote Opening Quote Award <br /> Change Order No. C/O & PCA No. PCA <br /> Ease/Encroach. Traffic Control: <br /> Other: <br />Required Information <br />Company or Vendor Name INDOT R-38064 <br />New Vendor <br /> Yes No If Yes, Approved by <br />Purchasing <br />MBE/WBE Contractor MBE WBE <br />MBE/WBE Contractor Requested No Yes Name of Company <br />Project Name R-38064 Coal Line Trail Phase I <br />Project Number 115-063 <br />Funding Source PR specific to this change order was created 04/25/2023 <br />Account No. PROJ00000018 <br />Amount 0.00 <br />Terms of Contract <br />Purpose/Description <br /> Change Order 8 covers time extension 410 days to complete Project. Original <br />Completion date of 08/15/2021 to 09/29/2022 <br /> Required Contractor’s Certification Forms Attached (Non- <br />Collusion, Non-Discrimination, Non-Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of Increase <br />Decrease $ <br />Previous Amount $ 1,871,262.79 <br />Current Percent of Change: 0.00 <br />New Amount $ 1,871,262.79 <br />Total Percent of Change: 15.247% <br />Dispersal After Approval <br />Copy Original <br />8X <br />X 410 Days