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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date May 20, 2019 <br />Name Roger T. Nawrot <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date May 28, 2019 <br />Phone Extension 5932 <br />MMMMIMIMIM�ywd �ruuouuuuuuuuuuuumwwm ,urn <br />.... <br />B�quired Prior t o Submittal to Board <br />. ... . ..... ...... ... <br />Legal F-1 <br />Attorney Name: <br />Controller El <br />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 />Check the A ropriate Item p <br />. ............ ..... __I�T _!�_::,_f�2_quired for All Submissions <br />—Prop6'salAddendum <br />Z <br />Agreement <br />- <br />Contract <br />Professional Services <br />F-1 Resolution <br />Bid Opening <br />0 Bid Award El Req. to Advertise El Title Sheet <br />El <br />Quote Opening <br />F-1 Quote Award <br />E] <br />Change Order No. <br />F-1 C/O & PCA No. F-1 PCA <br />0 <br />Ease/Encroach. <br />R Traffic Control: <br />F Other: <br />Rqq �ired �Infor!pAtion <br />Company or Vendor Name <br />Indiana & Michigan Power Compa!y <br />E] Yes 0 No E] If Yes, Approved by <br />New Vendor <br />Purchasi <br />MBE/WBE Contractor <br />F1 MBE [_1 WBE <br />MBE/WBE Contractor Requested <br />[:TY—esN—ame of Co—mp-.. . ...... <br />Project Name <br />Michiqan Street Reconstruction <br />Project Number <br />118-075 <br />Funding Source <br />RWTD <br />Account No. <br />324-1050-460.3102 <br />Amount <br />2,491.48 <br />Terms of Contract <br />LUMP S"y"Im, <br />Purpose/Description <br />New power service for Street Lighting and the Traffic signal at <br />Michigan Street and Wayne Street. <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />............... <br />R��.or.Chaqqq_,,Orders Only - - __-- - <br />Amount of increase <br />. $ ... ­ — — -------- <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />% <br />New Amount <br />.... - — ---- <br />Total Percent of Change% <br />. . . . . .............. . .... <br />.. . ...... . . <br />11 ....... . .... <br />Copy Original <br />F-1 D <br />F-1 <br />. . . ....... . . ..... <br />1-1 <br />