Laserfiche WebLink
BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 19, 2018 <br />Department Public Works <br />Name Roger Nawrot Division/Bureau <br />.....,........_.._............... _. <br />BPW Date November 27, 2018 Phone Extension 5932 <br />-�r�aaa✓�,�muuwuu�wiw�urw�ihr�rtr�uwv.,,�muwme��rurmmarrummmrmmmimmrwmmw��ae^�v�en����wuwww� � mnw immm�imm uriuiuuuiuuiuiui�uvrerc^rvwwwv� ��, ......., vaauvnmui�ew�umwti�mmmmir^�.... iomwam <br />Board <br />�� m _..._ .Required Prior to Submittal to �.. _m_.�_,.��........�.....—���.. .... <br />Legal ❑ Attorney Name: <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 El' <br />Check the <br />Agreement <br />El Professional Services <br />j Bid Opening <br />Quote Opening <br />® Change Order No. 4 <br />El Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />)ropriate Item Type — <br />M Contract <br />El Resolution <br />El Bid Award <br />El Quote Award <br />F] C/O & PCA No. <br />Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />d for All Submissions <br />:J Proposal <br />❑ Req. to Advertise <br />Reauired Information <br />❑ PCA <br />Indiana Department of Tr <br />ansportation <br />Addendum <br />❑ Title Sheet <br />Yeswp No If Yes, improved ley Purchasi <br />❑ MBE El WBE <br />0- .-" . es Name of Co <br />No . Y mpao.y. <br />SRTS Monroe Primaryand Studebaker Elementary R-3951„33 <br />116-039 <br />20% Federal 80° ° ............__�_ and City.....�....�r�r..._.....���....................................�.......... __�.� <br />This change order is for overruns and underruns of major <br />quantity amounts that exceed $20,000 in total amount of the line <br />item. When the change order is approved it is to be sent to <br />ry t DLZ Please e-mail it tqjMjl4qq@dlz.com <br />m <br />e e i ion a.. �— . <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />.__.., . ....Required For Char <br />Amount of Increase $ 16,222.27 <br />Decrease $ <br />Previous Amount $ 1,951,731.71 <br />Current Percent of 83 Change: 0. g 7% <br />New Amount $ 1,967,953.98 <br />Total Percent of Charge �1545%° <br />Dispersal After <br />Copy <br />Original <br />® <br />E] Roger Nawrot <br />❑ <br />E] <br />Orders On <br />roval <br />