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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />January 16, 2018 <br />Roger Nawrot-Kara Boyles <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />❑ Agreement <br />LJ Contract LJ Proposal LJ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control: <br />Other: Access Permit -- Survev <br />Permission <br />Company or Vendor Name <br />Indiana and Michigan Power Company <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor <br />❑ MBE ❑] WBE <br />MBE/VIBE Contractor Requested <br />❑ No ❑ Yes Name of Company <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Permission to enter in on City owned land for field survey and <br />geotechnical investigation at Boland Park, Beohm Park and <br />parcels along Boland Drive. I & M Power has a blanket <br />easement on these parcels of land. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of LJ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />