Laserfiche WebLink
BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />8/19/2016 <br />Blair <br />Department Public Works <br />BPW Date 8/23/2016 Phone Extension 5896 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® <br />George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />Indiana Earth <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />Project Name <br />Demolition of Vacant & Abandoned Houses, Phase IX - Division A & C <br />Project Number <br />116-074 <br />Funding Source <br />EDIT <br />Account No. <br />408.1201.415.39.89 <br />Amount <br />$ 181,800 Division A <br />$ 103,400 Division C <br />Terms of Contract <br />Unit <br />Purpose/Description <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Onlv <br />Amount of <br />Previous Amount <br />Increase <br />Decrease <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Dispersal After <br />Copy Original <br />® ❑ Elizabeth Maradik <br />® ❑ Toy Villa <br />