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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: <br />Name <br />01/16/2024 <br />Gemma Stanton <br />Department of Public Works — Engineering Division <br />BPW Date: January 23rd, 2024 Phone Extension: 9083 <br />Required Prior to Submittal to Board <br />BPW Attorney ❑ Attorney Name Michael Schmidt <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />I Check the Appropriate Item Tvne — Reauired for All Submissions I <br />U Professional Services Agreement U Contract <br />❑ Open Market Contract ❑ Amendment/Addendum <br />❑ Bid Opening ❑ Bid Award <br />❑ Quote Opening ❑ Quote Award <br />❑ Proposal Opening ❑ C/O & PCA No. <br />® Chg. Order, No. 5 ❑ Traffic Control <br />❑ Other: INDOT-LPA <br />Information <br />U Proposal <br />❑ Special Purchase, QPA <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />❑ Ease./Encroach <br />Company or Vendor Name <br />INDOT (Milestone Contractors performing work) <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />New Vendor <br />® No <br />❑ MBE El Yes <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached <br />❑ WBE ❑ No <br />Project Name <br />Coal Line Trail Phase IIB <br />Project Number <br />122-035 (INDOT DES #2200199) <br />Funding Source <br />PO-25244 <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Change Order #5 to extend intermediate completion date. Final <br />completion date (5/l/2024) remains the same. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <br />$ <br />Increase <br />Current Percent of Change: <br />Decrease <br />New Amount <br />$ <br />Increase <br />Total Percent of Change: <br />Decrease <br />Time Extension Amount: <br />98 days <br />New Completion Date: <br />5/l/2024 <br />