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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />05/07/2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 05/14/2019 <br />IIIIIIIIWN�II�d' kiFAPI��M��'1FfNIYfnl�il�YIIIIIIIIIIIIIIIIIIIIIIIIIW� NrY�IMII�IIII�MNd�+litllMdlld����PY�IMII�Wid���IlldIYFIIF.MM;MO <br />Phone Extension 574-235-9316 <br />A➢1➢ 11�5JWWIIIIWIWWI(l Wrygi <br />Required Prior to Submittal to Board <br />Legal <br />Attorney Name Clara McDaniels <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑l <br />and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing Z <br />Michael Schmidt <br />...... ...... _ww ..... .............. <br />Check the ,propriate Item Type — Required for All Submissions <br />Agreement <br />w ............... ........... <br />Contract El Proposal El Addendum <br />Professional Services <br />❑ <br />Amendment <br />Bid Opening <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />El <br />Quote Opening <br />Quote Award <br />❑] <br />Chg Order No. <br />El <br />C/O & PCA No. ❑ PCA <br />Ej <br />Ease./Encroach. <br />Ej <br />Traffic Control ❑ Resolution <br />Other: <br />El Claim <br />....................................._.. <br />Company or Vendor Name <br />Re orr ion Required f <br />._ .. <br />New Vendor <br />❑ <br />s If Yes, A roved b''-mmm <br />Ye pp y Purchasing <br />No <br />MBE/WBE Contractor <br />WBE Completed E-Verify Form Attached <br />Nees <br />Spec E — One (1) or more 2019 or newer One -Ton Crew Cab <br />Project Name <br />Four Wheel Drive Pickup Truck <br />Project Number <br />............. ............ ........... �........ �� .... <br />Funding Source <br />2019 Sewer D rtment Capital Budget mmm_ <br />Account No. <br />642-0621-415-43-02 <br />Amount <br />$41,899.00'................................. ..._.._.................................� <br />0 <br />Terms of Contract <br />Purpose/Description <br />Opening Bid Date: ................uw_�.,..............................................................�___.�. <br />Amount of �._.__......... r <br />For Change Orders Onlw <br />Increase $ �.� ........mm..m.......... <br />[_1 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 <br />Original <br />® <br />❑ Jeff Hudak <br />® <br />El Terri Swift <br />