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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date January 10, 2019 <br />Name Roger T. Nawrot <br />Department Public Works <br />Division/Bureau E............�............. <br />nginBering <br />BPW Date January 22, 2019 Phone Extension 5932 <br />wmummo mrwmw mmmmn000mmmumam mmmm <br />.� .._....._...................... Required Prior to Submittal to Board..........__................ <br />Legal Z <br />... Attorney Name: Clara McDaniel's <br />Controller El 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 />Checkthe <br />H Agreement <br />❑ Professional Services <br />E] Bid Opening <br />E] Quote Opening <br />R Change Order No. <br />Ease/Encroach. <br />F-1 Other: <br />Company or Vendor Name <br />iropriate Item Type — Required for All Submissions <br />❑ Contract ProposalmITITmm-.._...___ <br />E] Resolution <br />Bid Award Req. to Advertise <br />Quote Award <br />E C/O & PCA No. PCA <br />Z 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 />Amount of LJ Increase <br />F Decrease <br />Previous Amount $ <br />................ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Chance: <br />Copy <br />Original <br />❑ <br />R <br />❑ <br />R <br />Reluired Information <br />Addendum <br />❑ Title Sheet <br />Indiana Michigan Power Company <br />❑ Yes ® No 0 If Yes, Approved by _- <br />Purchasing <br />.._.....W ........ <br />❑ MBE F WBE <br />G 1 No Yes Name of Comoanv <br />The restricting of a blanket electrical line easement on the <br />Organic Resources Property to a corridor that is 100 feet wide <br />based upon the existing line location in the south part of the <br />" Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />red For Change Orders Onl <br />Dispersal After r <br />Please sent all documents to Marc Lane, ROW Supervisor at <br />_tract Land Staff, .... 104 South Broadway Street, Cassopolis MI 49031 <br />Office 269-738-4286Cell 218-3938.9......... <br />0- w _._................_—. <br />0 <br />