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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />12/19/17 <br />Adam Parsons <br />Department Central Services <br />BPW Date 12/21/17 Phone Extension 574-235-9302 <br />L.1 Agreement <br />LJ Contract LJ Proposal LJ Addendum <br />❑ Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />® <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />n <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBEANBE 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 />Amount of <br />Industrial Door of Northern Indiana <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />I-1 MBE n WBE <br />❑ No ❑ Yes Name of Company <br />Spec AJ — Repair & Installation of Overhead Doors for All City <br />Departments <br />Various Department's Operating Budgets <br />TBD (hourly rates attached) <br />Bid Opening Date: 12/12/17 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Adam Parsons, Dave Qualls, & Sheila Enos <br />❑ ❑ <br />❑ ❑ <br />