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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />03/01 /2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date March 12, 2019 Phone Extension 574-235-9316 <br />m�wuuuuuuuum 11 .. mr 111111 mom= ; +a �r�w a„�555=im i m^r m <br />m, ...._�. <br />_.....e.. ,,,.,,e, ._.. ...... <br />w lire Prior to Submittal to Board <br />....�� ..� _ ..�..._.... - _................... <br />Legal <br />Attorney Name Clara McDaniels <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ <br />and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ® <br />Michael Schmidt <br />a� .._.._. ...... _ _�.111 ,...�,. <br />Check the Appropriate Item Type — Required for All Submissions <br />� - <br />Agreement <br />0 g <br />...._� .. _.�..._� <br />[l Contract ❑ Proposal Addendum <br />❑ Professional Services <br />[:] Amendment <br />❑ Bid Opening <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Chg Order No. <br />F] C/O & PCA No. <br />PCA <br />❑ Ease./Encroach. <br />E] Traffic Control <br />Resolution <br />R <br />Other: <br />Claim <br />Company or Vendor Name <br />New Vendor <br />............_._.. <br />Yes 0 If Yes, Approved by Purchasing <br />[1 No <br />MBE/WBE Contractor <br />n WBE Completed E-Verify Form Attached � Nos <br />p I� <br />Spec F — One (1) more Self -Propelled Easement Machine <br />Project Name <br />with Expandable Track -Drive and TrailerS <br />......... .�............ �._..........M .. .._................- <br />Project Number <br />................ <br />Funding Source <br />_....._....-____..._ ........... <br />2019 Sewer Department Capital Budget <br />. ...................... . _........ _ _......_ <br />Account No. <br />642-0621-415-43-02 <br />Amount <br />Terms of Contract <br />Purpose/Description <br />. _..... . _ ............. _................_ <br />Opening Bid Date: April 9, 2019 <br />Amount of ❑ Increase <br />[:] Decrease <br />$ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />% <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />®El <br />Jeff Hudak <br />® <br />❑I Terri Swift <br />0 <br />El <br />