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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date October 17, 2016 Department <br />Name Theresa E. Harrison, P.E., ENV SP Division/Bureau <br />Public Works <br />Engineering <br />BPW Date October 25, 2016 Phone Extension 5933 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name: Michael Schmidt <br />Controller ❑ <br />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 El <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />❑ <br />Agreement <br />Professional Services <br />® Contract ❑ Proposal ❑Addendum <br />El Resolution <br />❑ <br />❑ <br />Bid Opening <br />Quote Opening <br />❑ Bid Award ❑ Req. to Advertise <br />El Quote Award Title Sheet <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />Indiana Department of Transportation <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />New Vendor <br />Purchasing <br />MBE/WBE Contractor <br />0 MBE WBE <br />MBE/WBE Contractor Requested No ❑ Yes Name of Company <br />Project Name <br />South Bend Signal Maintenance <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$0 cost to City; City is paid by INDOT as outlined in Contract <br />Terms of Contract <br />Purpose/Description <br />This is a contract between the City and INDOT for the City to <br />_provide "first response" for INDOT owned traffic signals <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Py <br />Original <br />® <br />❑ <br />® ❑ <br />ired For Chanqe Orders <br />Original, signed document to be returned to INDOT <br />Ed Gleckler, Manager, Traffic & Lighting Bureau <br />Scanned, signed copy to engineering folder: S:\Public <br />•-"•^"�•• •""^aiui,�n�uvi -fill UI J� IraIIIc JI nai maintenance <br />Contract\2016-10-17 Traffic Signal Maintenance Contract <br />