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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />March 19, 2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date March 26, 2018 Phone Extension 574-235-9316 <br />��raor�urrrrd�a,�erv+e�rrrr�r� r �A.�awr,,,,,�,,,r r�:m = ,._ �•... �.�wuWiarm�rsmuws�m�uuawwuaW�,�ro�iarw�aw�uuuuuuuuuumm e�ir�rn,�arm,�::�ru�emm�eu�.:��- ,.,.��,� iuiMo uw�nm�rmnrra!� <br />uired Prior to Submittal to Board <br />Legal ® Attorney Name Clara McDaniels <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® Michael Schmidt <br />Check the <br />H Agreement <br />El Professional Services <br />El Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. _ <br />Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />M <br />Item Type —ontract <br />[� Resolution <br />Bid Award <br />0 Quote Award <br />F1 C/O & PCA No. <br />El Traffic Control <br />or All Submissions <br />Propos .al .....� <br />® Req. to Advertise <br />Required Information <br />❑ PCA <br />Yes LJ No If Yes, Approved_bmmPurchasi <br />MBEI WBE <br />Addendum <br />❑ Title Sheet <br />El No El Yes ............Name o........... f...Com; any ........_.__�............................. <br />Spec I — One (1) or more 2019 or Newer 18,000 lb. Four Wheel <br />Drive Chassis with Custom Flat Bed <br />2019 Street DepartmentLeaseBudget <br />Principal #202-0607-431-38-01 Interest #202-0607-431-38-02 <br />Bid Opening Date: April 23, 2019 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Rerire For Chanqe Orders Only <br />Amount of El Increase _$ <br />R Decrease $ <br />Previous Amount $ <br />..................... <br />_............_...._. <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: mm._..... <br />Dispersal µAfter Approval <br />Copy <br />Original <br />® <br />E] Jeff Hudak <br />® <br />❑ TerriSwift <br />® <br />El Sean Ward <br />