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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date May 23, 2019 <br />Name Jeff Hudak <br />Department Central Services <br />BPW Date June 11, 2019 Phone Extension 574-235-9316 <br />rvu�r��i�muuuuuuuuumwu�u%mu�w�uw�u�u��emminam�mmmm�mm� � , �imrircmrn�✓n nrn✓„���seua� .-�,.�.�,��,. ::um�,.�.w.�cazr �arz,._.. sznr�nw�:..����muwnrum^�awuiuiuiuiuimiuw�iwiurmw�rv�w�uiuu�uuurrrcrr�✓rs�r„mr�.az�r�ss� r�ra;inm,—._. <br />Check the <br />H Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑] Change Order No. _ <br />El Ease/Encroach. <br />F-1 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 />Amount of <br />Required Pri.�o.�r..to..�.S�u..bm.i.'tt B ..__._..� <br />R Submittal to Board <br />dropriate Item Tape <br />Contract <br />Resolution <br />® Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />Required for All Submissions <br />E] Proposal <br />❑ Req. to Advertise <br />Required Information <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Yes L_J No LJ If Yes,_Aaroved by Purchasin <br />MBE FI WBE <br />.. No El Yes Name of Com?.anv <br />..!........................................................_�.........��........... �,,.m <br />Spec K One (1) y Machine <br />or ore or ewer ti it or <br />2019 , Capital Budget Venues, Parks Arts ..... <br />406-1101-452.42-01 <br />..�.�..._..2... <br />.......... <br />57,254.6. _..... .w.m,.................................m_..........................................................................�......... __��... <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non-Discri.minanation, Non -Debarment, E-Verify, Iran„ etc. <br />�... <br />R �. w w .-_ <br />_ Wired For hn Orders nC + <br />Increase $..... _.. <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />Copy Original <br />® ❑ Jeff Hudak <br />® ❑ Ken Glowacki <br />0 ❑ <br />Dispersal After Approval <br />