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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Name Roger Nawrot _ Department En ineerin <br />BPW Date 02132018 Phone Extension <br />Re aired Prior to ubm,, ittaif E oard. <br />Legal Attorney Name <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing <br />® Agreement <br />❑ Professional services <br />❑ Bid Opening <br />[ Quote Opening <br />❑ Chg Order No. <br />❑ Ease./Encroach. <br />❑ Other. <br />❑ Contract n Proposal <br />❑ Amendment <br />❑ Bid Award ❑ Req. to Advertise <br />■ Quote Award <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control [ Resolution <br />® Claim <br />LJ Addendum <br />❑ Title sheet <br />Required Information <br />Company or Vendor Name <br />INDOT <br />■ Yes ❑ If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />MBEI'NBE Contractor <br />❑ MBE Completed E-Verify Form Attached <br />❑ WBE <br />El Yes <br />❑ No <br />Project Name <br />Project Number <br />Funding source <br />Local Roads and Bridges Matching Grant <br />Account No. <br />Amount <br />$670,000; 50/50 Matching Grant <br />Terms of Contract <br />_ <br />Purpose/Description <br />Reconstruction of North Ironwood Derive from McKinley Ave. to <br />South Bend Ave. <br />Amountof ❑ Increase $ <br />❑ Decrease <br />Previous Amount <br />$ <br />Current Percent of Change: <br />°!a <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Time Extension: <br />Dispersal After Approval <br />Original <br />■ <br />