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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 7/17/17 <br />Name Matt Chlebowski Department <br />Central Services <br />BPW Date 7/25/17 Phone Extension 574-235-9316 <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. ❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />Other: Special Purchase <br />Company or Vendor Name Brown Equipment Compan <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBEIWBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />Special Purchase X — One (1) 2017 or Newer Heavy Duty 14,500 <br />Project Name <br />lb. GVWR Truck & Multiconductor TV/Lateral Inspection System <br />Project Number <br />Funding Source <br />2017 Sewer Department Capital Budget <br />Account No. <br />642-0621-415-43-02 <br />Amount <br />$ 285,000.00 <br />Terms of Contract <br />Purpose/Description <br />Bid Opening Date: NIA <br />❑ Required Contractor's Certification Form Attached (Non= <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Re' u�red For:Chari <br />e Orders Oily, <br />Amount of ❑ <br />❑ <br />Increase $ <br />Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: % <br />New Amount <br />$ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ <br />Matt Chlebowski & Sheila Enos <br />® ❑ <br />Terri Swift, Derick Roberts, Dale Helpingstine <br />❑ ❑ <br />