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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01/03/2017 Department Public Works <br />Name <br />Kevin Fink <br />Division/Bureau <br />Engineering <br />BPW Date <br />01/10/2017 <br />Phone Extension <br />5903 <br />I 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 />I Check the Appropriate Item Type — Required for All Submissions <br />® <br />Agreement <br />❑ Contract ❑ Proposal ❑Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />F] <br />Other: <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 Chanae: <br />Copy <br />Origin <br />0 <br />❑ <br />Information <br />❑ Yes 0 No ❑ If Yes, Approved by <br />Purchasing <br />MBE ❑ WBE <br />No Yes Name of Company <br />Boland Trail <br />113-047 <br />Supplement to INDOT-LPA contract to revise schedule for <br />receiving federal funds <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Roger Nawrot <br />Kevin Fink <br />uired For Change Orders <br />