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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: <br />Name <br />January 16, 2024 <br />Leslie Biek Department of Public Works — Engineering Division <br />BPW Date: January 23, 2024 Phone Extension: 9323 <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing <br />I Check the ADDroDriate Item TVDe — Reauired for All Submissions I <br />U Professional Services Agreement U Contract U 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 />n Other: 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 />DLZ Indiana <br />U Yes❑ If Yes, Approved by Purchasing <br />® No <br />E] MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Bendix Drive Improvements (Lathrop to Voorde) <br />121-047; INDOT DES2100022; PROJ 338 <br />PO 15848 <br />RWTIF <br />$270,940 <br />NTE <br />Design and R/W professional services for Bendix Ph 2. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />New Completion Date: <br />Increase % <br />Decrease ( %) <br />Increase % <br />Decrease ( %) <br />