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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date June 17, 2019 <br />Name Jeff Hudak <br />Department Central Services <br />BPW Date June 25„ 2019 Phone Extension 574-235-9316 <br />Required Prior to Submittal to Board <br />_ ......... _................... .... <br />Legal ® Attorney Name Michael Schmidt ... <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 ® George King <br />Check the <br />LJ Agreement <br />Professional Services <br />El Bid Opening <br />Quote Opening <br />Change Order No. _ <br />L] 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 />iropriate Item Type — <br />Contract <br />Resolution <br />® Bid Award <br />❑ Quote Award <br />❑ C/O &PCANo. <br />_ <br />❑ Traffic Control <br />uired for All Submissions <br />1 Proposal <br />0 Req. to Advertise <br />Required Information <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />No L 1 If Yes, Approved by Purchasin <br />El <br />o ❑ Yes Name of Company, <br />uN .._� __.........._... <br />Spec O — Two (2) More or Less 2019 or Newer Mid -Size Extended <br />Cab Four Wheel Drive Pick Up Truck <br />2019 Code Enforcement Capital Lease & Interest <br />Lease 612-1201-415.38.01 Interest 612-1201-415.38.02 <br />59..66�8...O.��................................w..w............ <br />........................— <br />❑ Required Contractor's Certification Form Attached w W ww (Non - <br />Collusion, Non -Discrimination Non-Debarme,nt,wE Verily, Iran, etc <br />H�..�.e..,m......�m_.�mRequire ForChange Orders Oni......�_.....�.�...�_�_�..�_ <br />Amount of Increase $ <br />F] Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />Copy Original <br />® Jeff Hudak <br />® El Ron O'Connor <br />® Tracy Skibins <br />Dispersal AfterApproval <br />