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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />3/13/2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date March 26, 2019 Phone Extension 574-235-9316 <br />�Nlffi WMAN W-� <br />Re.90red, P`r!.o`r.toSubmittal to Board <br />Legal Attorney Name Clara McDaniels <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ] and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing <br />Check the P <br />"Agreement <br />El Professional Services <br />E:1 Bid Opening <br />E:1 Quote Opening <br />El Chg Order No. <br />El Ease./Encroach. <br />R Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Michael Schmidt <br />pro r ate-Itern T�e - Re <br />Contract <br />r-1 Amendment <br />d for All Submissions <br />I Proposal <br />Bid Award Req. to Advertise <br />❑ Quote Award <br />C/O & PCA No. ❑ PCA <br />❑ Traffic Control ❑ Resolution <br />Claim <br />Reauired Information <br />Addendum <br />El Title Sheet <br />- . ......... <br />El Yes [:1 If Yes, Approved by Purchasing <br />F-1 No <br />WBE 0E-1 ❑Nos <br />Completed E-Verify Form Attached <br />Spec D - One (1) or More 2018 or Newer Truck Mounted <br />Automatic Pothole Patcher <br />2019C Capital Le�asePrincoal & Interest Street Department <br />P -202-0607-431-38-01 1 -202-0607-431-38-02 <br />Opening Bid Date: April 23, 2019 <br />For Change Orders Only <br />Amount of El increase <br />E] Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy Original <br />® F-1 Jeff Hudak <br />- - - --- - ---- - ............. <br />............... <br />El El <br />