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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 09/19/2018 <br />Name Kara Boyles /Alicia Czarnecki Department Engineerin <br />Purchasing <br />® Michael Schmidt <br />❑ Agreement <br />❑ Contract ❑ Proposal ❑ 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 />n Other: <br />Company or Vendor Name American Structurepoint_ <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor ❑ MBE ❑ WBE <br />MBEANBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name Traffic Signal Engineering On Call <br />Project Number 118-095 <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of ❑ <br />El <br />LRSA <br />251-0608-431.36-67 <br />$ 25,000.00 <br />Lump sum base bid with alternates <br />Emergency Purchase Order for repair at 2222 Mishawaka Avenue <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc.) <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />4/Q <br />4/Q <br />Dispersal After Approval <br />