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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 4, 2017 <br />Name Roger Nawrot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />❑ Agreement Amendment <br />H Contract LJ Proposal Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ <br />Traffic Control: <br />RI Other: Recommendation for Acceptance <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />MBEIWBE Contractor Requested <br />Project Name <br />Project Number <br />Indiana Department of Transportation <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Olive -Sample Overpass <br />113-002 <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />