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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 6, 2016 <br />Name Roger Nawrot Department Engineering <br />BPW Date September 13, 2016 Phone Extension 5932 <br />I 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 ® George King <br />Check the Appropriate Item Type — Required for Aii Submissions <br />❑ Agreement ❑ 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 />F- Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chance: <br />Copy <br />Origin <br />® <br />❑ <br />Information <br />DLZ Indiana, LLC <br />❑ Yes ® No <br />LJ No L_J Yes Name of Company <br />Emergency Repair of Ireland Road at Hiah Street <br />116-0838 G <br />Major Moves <br />412.0602.431.42.03 <br />$17,430.00 <br />Not to Exceed <br />To prepare bid documents to repair the spillway washout out <br />caused by the August storm.. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination _ Nnn-nP.harmP..nt F-\/arifv Iran afr 1 <br />Nawrot <br />