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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />December 18, 2017 <br />Kara Boyles <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />❑ Agreement <br />❑ Contract H Proposal L.j Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control: <br />�) <br />Other: Amendment No. 1 to MOU with County <br />Company or Vendor Name <br />MOU with St. Joseph County for Portage Avenue Bridge <br />❑ Yes M No if Yes, Approved by <br />New Vendor <br />Purchasing <br />MBEIWBE Contractor <br />❑ MBE ❑ WBE <br />MBEIWBE Contractor Requested <br />❑ No ❑ Yes Name of Company <br />Project Name <br />Portage Ave. Bridge Over Conrail Structure Replacement <br />Project Number <br />NIA <br />Funding Source <br />MVH <br />Account No. <br />202-0607-431.36-01 <br />Amount <br />$12,000 <br />Terms of Contract <br />City's shared cost of project with Count — Change Order <br />Purpose/Description <br />City's requested elements of the County's bridge replacement <br />project in 2017 <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of <br />Previous Amount <br />❑ increase $ <br />❑ Decrease $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />