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Date 9-20-2016 <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department Public Works <br />Name Roger Nawrot Division/Bureau Engineering <br />BPW Date 9-27-2016 Phone Extension 5932 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <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 All 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 />❑ Other: <br />_ Required Information <br />Company or Vendor Name Indiana Mich <br />I-1 Yes I-1 N <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 ❑ Increase <br />❑ Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanoe: <br />py <br />Original <br />❑ <br />❑ <br />Ian Power Corn <br />Approved by <br />U MBE 11 WBE <br />❑ No Ll Yes Name of Company <br />Olive Road Lighting over the Indiana Toll Road <br />115-124 <br />404-0602-431.31-06 <br />$3,694.64 <br />conversion of existing 3 phase power service to single phas, <br />power service for the lighting project. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Nawrot <br />