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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />1 /30/17 <br />Matt Chlebowski <br />Department Central Services <br />BPW Date 2/14/17 Phone Extension 574-235-9316 <br />Re uired Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® George King <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of ❑❑ <br />nt <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />n MBE ❑ WBE <br />No ❑ Yes Name of Corn <br />Spec — (B)One or more or less 2017 or newer Single Axle Lightning <br />Loader <br />2017 Solid Waste Capital Lease Principal 611-0610-415-3711/ <br />Interest 611-0610-415-3712(subject to lease funding) <br />611-0610-415-3711/611-0610-415-3712 <br />$ 190,402.00 <br />Bid Opening Date:12/13/16 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <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 />® <br />❑ <br />Dispersal After Approval <br />Matt Chlebowski, Sheila Enos, <br />Wisniewski, Central Services <br />Mike Bronstetter & Carol Kurzhal, Solid Waste <br />