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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />December 19th, 2016 <br />Kevin Fink <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date December 22°d, 2016 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 />Terms of Contract <br />Purpose/Description <br />Amount of <br />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 />Lochmueller Group, Inc. <br />❑ Yes ® No ❑ If <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Edison and Ironwood Road Corridi <br />116-070 <br />LOIT 2016 Special Distribution <br />257-0608-431.31.06 <br />to Exceed <br />Corridor improvements along Edison from Hickory to Duey and <br />along Ironwood from McKinley to Mishawaka <br />II Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Roger Nawrot <br />Kevin Fink <br />ired For Chanae Orders <br />