Laserfiche WebLink
Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />February 6, 2017 <br />Nawrot <br />Department Public Works <br />BPW Date February 14, 2017 Phone Extension 5932 <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 />LJ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. <br />Ease/Encroach. <br />Other: <br />U Contract L Proposal U Addendum <br />❑ Resolution <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Award <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control <br />Required Information <br />Company or Vendor Name <br />American Structurepoint, Inc. <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />Additional South Bend Downtown Road, Traffic and Signal <br />Project Name <br />Improvements Work <br />Project Number <br />115-019 <br />Funding Source <br />TIF Bond <br />Account No. <br />Amount <br />$50,000.00 <br />Terms of Contract <br />Not to Exceed <br />Purpose/Description <br />Additional Traffic Design and Road Design Services. <br />X Required Contractor's Certification Form Attached (Non -Collusion, <br />Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Amount of H 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 />❑ <br />❑ <br />Nawrot <br />in <br />Dispersal After Approval <br />