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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10-31-16 Department Public Works <br />Name Kevin Fink Division/Bureau Engineering <br />BPW Date 11-08-16 Phone Extension 5903 <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 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 <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 />Troyer Group, Inc. <br />❑ Yes ® No ❑ If Yes, i <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Lincoln Primary Center Safe Routes to <br />116-078 <br />Local Roads and Streets <br />•• 1:m 11 <br />10-99 <br />Terms of Contract 80/20 Match with INDOT <br />Purpose/Description Construction Inspection Services <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <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 />Nawrot <br />Dispersal After <br />