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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date October, 15, 2018 <br />Name Jeff Hudak Department Central Services <br />BPS/ Date October 23, 2018 Phone Extension 574-235-9316 <br />. ...... ..... . <br />Required Prior to Submittal to Board <br />Legal Z Attorney Name Clara McDaniels <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing Z Michael Schmidt <br />Check the Appropriate Item Type_— Requiredfior All Submissions <br />F1 Agreement E] Contract [:1 Proposal El Addendum <br />n Professional Services F1 Resolution <br />[:1 Bid Opening El Bid Award El Req. to Advertise Title Sheet <br />Quote Opening ❑ Quote Award <br />❑ Change Order No. C/O & PCA No,. ❑ PCA <br />❑ Ease/Encroach. El Traffic Control <br />Other: Relect all Bids <br />Company or Vendor Name <br />New Vendor 1: <br />MBE/WBE Contractor E <br />MBE/WBE Contractor <br />-Required Information <br />,Yes LJ No Ll IIf Yes, Approved by Purchas <br />MBE [_1 WBE <br />Requested El No El Yes Name of Company <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Spec I — One (1) more of-lets-20118 or Newer 3/4 Ton Two Wheel <br />Drive Pick Up Trucks <br />2016 Water Works Capital Budget <br />622-0640-415-,43-02 <br />F] Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -,Debarment, E-Verifv, Iran, etc. <br />n increase $ A1`1%t)VL1,'D <br />Amount of El Decrease $ rd of r,75,10ic <br />Previous Amount <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original ' <br />M n Jeff Hudak <br />Fq E] Roxanne Lawson & Ed Herman <br />El El <br />