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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />03/10/17 Department Public Works <br />Toy Villa <br />Division/Bureau Engineering <br />BPW Date 03/28/17 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <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 />F Other: <br />Company or Vendor Name <br />New Vendor <br />MBEANBE 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 />Amount of <br />Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />uired Information <br />Michiana Contracting, Inc. <br />Yes M No <br />It Yes, Approved by <br />❑ No ❑ Yes Name of Company <br />Olive Road Lighting over the Indiana Toll Road <br />115-124 <br />COIT <br />404.0602.431.31.06 <br />$32,211.00 <br />Proiect Closeout <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc. <br />For Chanae Orders <br />After Approval <br />