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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />March 19. 2018 <br />Jacob M. Klosinski <br />Department Utilities - Wastewater <br />BPW Date March 27, 2018 Phone Extension 574 235-9496 <br />U Agreement <br />U Contract <br />❑ Proposal U Addendum <br />❑ <br />Professional Services <br />❑ Amendment <br />❑ <br />Bid Opening <br />❑ Bid Award <br />® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Chg Order No. <br />❑ CIO & PCA No. <br />❑ PCA <br />❑ Ease./Encroach. <br />❑ Traffic Control <br />❑ Resolution <br />n Other: <br />F-1 <br />Claim <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />"" """"` v' ❑ Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy Original <br />® ❑ Al Greek, Director of Utilities <br />® ❑ Jacob M. Klosinski, Assistant City Engineer <br />® ❑ Emily Leyes, Director of Financial Services, Environmental Services <br />