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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 20, 2016 <br />Department Public Works <br />Name Corbitt Kerr Division/Bureau Engineering <br />BPW Date February 28, 2016 Phone Extension 5931 <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 />I-1 Other: <br />Required Information 1 <br />Company or Vendor Name <br />JPR <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />New Vendor <br />Purchasing <br />MBE/WBE Contractor <br />H MBE ❑ WBE <br />MBE/1NBE Contractor Requested <br />No ❑ Yes Name of Company <br />Project Name <br />Monroe Parking Lot and Street Improvements <br />Project Number <br />117-043 <br />Funding Source <br />RWDATIF <br />Account No. <br />324-1050-460-3102 <br />Amount <br />$25,125.00 <br />Terms of Contract <br />Lump Sum, Not to Exceed <br />Purpose/Description <br />Provide services for the design of a Parking Lot at the old <br />Michiana Lock and Key Site and improvements on Monroe. <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ❑ Increase <br />❑ Decrease <br />$ <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 />❑ 0 <br />