Laserfiche WebLink
Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />1 /30/17 <br />Kara M. Boyles <br />Department <br />Division/Bureau <br />Engineering <br />DPW <br />BPW Date 2/14/17 Phone Extension 5933 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: M. Schmidt <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />® Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />❑ Other: <br />Company or Vendor Name <br />St. Joseph County Regional Water and Sewer District <br />❑ Yes ® No ❑ If Yes, Approved by <br />New Vendor <br />Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested <br />N No ❑ Yes Name of Company n/a <br />Project Name <br />Master Agreement — First Amendment <br />Project Number <br />N/A <br />Funding Source <br />N/A <br />Account No. <br />N/A <br />Amount <br />N/A <br />Terms of Contract <br />N/A <br />Purpose/Description <br />Amendment re: renewal terms (original agreement expired); <br />See attached Original Master Agreement and Amendment No 1 <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Onl <br />Amount of ❑ Increase <br />$ <br />❑ Decrease <br />$ <br />Previous Amount $ <br />Current Percent of Change: <br />% <br />New Amount $ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />