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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 3, 2018 <br />Name Becca Plantz <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date December 11, 2018 Phone Extension 5998 <br />wawmmrmrimi uummmmmmmmmmmmmmmmmmmuuuuwiwmumwiu <br />red Prior to Submittal to Board <br />Legal ❑ 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 ❑ <br />Check the Appropriate Item TVDe — <br />H Agreement Amendment <br />Professional Services <br />EJ Bid Opening <br />0 Quote Opening <br />❑ Change Order No. <br />Ease/Encroach. <br />Other: Access Permit <br />Contract <br />El Resolution <br />El Bid Award <br />El Quote Award <br />C/O & PCA No.. <br />❑ Traffic Control: <br />Company or Vendor Name <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 />I eauired Information <br />AEPI&M <br />for All Submissions <br />Proposal <br />Req. to Advertise <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Indiana Michigan Power I & M Access Permit Request <br />Indiana Michigan Power is requesting access to the Northeast <br />corner of Muessel Grove Park for a soil boring to survey for a <br />proposed electric transmission line route. <br />L..J Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Regiuired F©r �ahge �rderr +rub^ <br />Amount of <br />�] Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of ChaneITmmm µmm m wwwwww wwwwwwwww % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Becca Plantz <br />❑ ❑ <br />0 El <br />