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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 9, 2016 <br />Name Blair Spotts Department Engineering <br />BPW Date September 13, 2016 Phone Extension 5998 <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 />Check the Appropriate Item Type — Required for Ail Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise <br />El Quote Opening ® Quote Award ❑Title Sheet <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Information <br />Michiana Contractin , Inc. <br />❑ Yes ❑ No If Yes Approved by Purchasin <br />❑ MBE I —I WBE <br />_❑ No ❑ Yes Name of Company <br />Traffic FUR Cameras at Cleveland Rd and Ameritech Dr <br />115-131B <br />Maint. <br />251 <br />Unit <br />Traffic detection cameras at Ameritech Dr and Cleveland Rd <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Amount of LJ Increase $ <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />Corbitt Kerr <br />ivawrot <br />U�0 <br />Dispersal After Approval <br />