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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date June 6, 2019 <br />Name Jeff Hudak <br />Department Central Services <br />BPW Date June 25, 20119 Phone Extension 574-235-9316 <br />1VGW'dMMININ@'IPllflllfl@mM°Wlklklk'IkYIpMIMtM!WU'u"!PN YttRttkkrY'�"ItlY t4 ova rvv:v„r+vidiw',i. d , �� ,.-sGel9,'v.YlfrvRl"e pdwlW IW^,VMIWfiNtlll, ImIN2iYsNM:R"ww�.,.i,,,,;SY;�mc—'�u'�+� ^++u+,nA✓vNCPC'NdW9dl'IWII81141 41 41 41 41NIIIIIIIIIIIIIIIIIIIIIIIIMII'vlll'Ar <br />mm <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 ❑ <br />and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ® <br />Michael Schmidt <br />.. gip. �_ p q .u. - <br />Check the A ro riate Item T e — Re urre for All Submissions <br />El Agreement <br />El Contract E] Proposal Addendum <br />❑ Professional Services <br />El Amendment <br />❑ Bid Opening <br />® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />Quote Award <br />Ej <br />Chg Order No. <br />C/O & PCA No. <br />[ <br />PCA <br />El <br />Ease./Encroach. <br />❑ Traffic Control <br />El <br />Resolution <br />Other: <br />[ <br />Claim <br />.....� ....... <br />_.. <br />Required Information <br />Company or Vendor Name <br />_ <br />If Yes .Approved b................. ............ <br />chasing _....�_......... <br />New Vendor <br />❑ No <br />MBE/WBE Contractor <br />❑ MBE Completed E-Verify Form Attached El Yes <br />❑ WBE ❑ No <br />Spec M — One (1) or More 2019 or Newer Combination Jet <br />Project Name <br />Rodder/Vacuum Machine with Cab & Chassis <br />Project Number <br />_ _ <br />Funding Source <br />2019 Sewer Department <br />t Capital Budget ,.m .....................—. <br />Account No. <br />642-0621-415-43-02„. <br />Amount <br />$361,864.00 <br />Terms of Contract <br />Purpose/Description <br />Amount of Ll Increase <br />El Decrease <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />Time Extension: <br />Copy Original <br />® [� Jeff Hudak <br />® ""Terri Swift <br />❑❑ <br />For C <br />AMMM41111 <br />Dispersal After Approval <br />