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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 03/06/2017 Department Public Works <br />Name Rich Estes Division/Bureau Engineering <br />BPW Date 03/14/2017 Phone Extension 5896 <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 ® George King <br />Check the Appropriate Item Type — Reauired for All Submissions <br />H <br />Agreement A Contract LJ Proposal LJ Addendum <br />® <br />Professional Services ❑ Resolution <br />❑ <br />Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening ❑ Quote Award <br />❑ <br />Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. ❑ Traffic Control: <br />® <br />Other: Amendment 1 <br />Required Information <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 />DLZ Indiana, LLC. <br />RWDA TIF <br />324-1050-460.42-03 <br />Addl+�ro1 Not To Exceed $1000.00 <br />Survey additional new surface at the location where the phase I <br />improvements ended on Sheridan. <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of " Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Patrick Kerr <br />❑ ® Qasim Asghar (DLZ) <br />® ❑ Kara Boyles <br />