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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 9-20-2016 Department <br />Public Works <br />Name <br />Blair Spotts <br />Division/Bureau <br />Engineering <br />BPW Date <br />9-27-2016 <br />Phone Extension <br />5998 <br />I Required Prior to Submittal to Board <br />Legal ® Attorney Name: MS <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 />I 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: Amendment to INDOT Contract <br />Required Information <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 />INDOT <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Com Danv <br />to School <br />ENG: 114-066 INDOT: DES# 1400635 <br />Local Roads and Streets <br />251-0608-380.10-99 <br />80% Federal/ 20% Local <br />Increase contract amount <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />I Required For Change Orders Only <br />Amount of ® Increase $ 89,578.55 <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 />1 <br />M <br />After <br />