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Date <br />Name <br />9-20-2016 <br />Blair Spotts <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 9-27-2016 Phone Extension 5998 <br />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 />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 />® 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 />U MBE U WBE <br />_ No ❑ Yes Name of Company <br />Harrison Primary School: Safe Routes to School <br />DES. No.: 1400636; ENG: 114-067 <br />Local Roads and Streets <br />251-0608-380.10-99 <br />$1,027,617.35 <br />80% Federal/ 20% Local <br />contract amount <br />U Kequired Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />I Required For Change Orders Only <br />❑ <br />❑ <br />❑ <br />❑ <br />