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w <br />312/17 <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department Central Services <br />BPW Date 3/14/17 Phone Extension 574-235-9316 <br />Jeff Hudak <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 LJ Proposal U 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 />F 1 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 />'IT1._1 <br />LJ Yes LJ No U If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />No LJ Yes Name of Con <br />Spec — (F) Three or more or less 2017 or newer Four Door Hybrid <br />Utilitv Vehicle <br />2017 Building Dept Capital Lease Principal 600-1306-415- <br />3711/Interest 600-1306-415-3712(subject to lease funding) <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. 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 />❑ Jeff Hudak & Sheila <br />® <br />❑ Laura Althoff, Buildii <br />❑ <br />❑ <br />Approval <br />Central Services <br />