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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />Auaust 19. 2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date A,RguLst.27, 2019 Phone Extension 574-235-9316 <br />uvia...l� I! � I! Pm wwwwwwwVhJ � "I", �11 7a : 0 41 <br />..................... <br />Rye„cfuired 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 />. . . ......... <br />Check the._4propLiq "eterp y _T_pe - - ---- Regu�qq for All Submissions <br />. . . ...... ... .......... <br />F-1 Agreement <br />❑ <br />Contract 0 Proposal El Addendum <br />In Professional Services <br />Amendment <br />El Bid Opening <br />Bid Award ❑ Req. to Advertise E] Title Sheet <br />F-1 Quote Opening <br />F-1 Quote Award <br />[:] Chg Order No. <br />F-1 C/O & PCA No, <br />PCA <br />F] Ease./Encroach. <br />F-1 Traffic Control <br />El Resolution <br />El Other: <br />F-1 Claim <br />Required Information <br />Company or Vendor Name <br />New Vendor El Yes F1 If Yes, Approved by Purchasing <br />E] No <br />MBE/WBE Contractor n MBE Completed E-Verify Form Attached El Yes <br />n WBE EJ No <br />Project Name .29) More or Less Brand New Leaf Boxes <br />-§Pe�qB-=T P�Y.NLnE, L( <br />Project Number <br />Funding Source Street De artment - Capital Lease & Interest <br />Account No. 202-0607-431.38.01 & 202-0607-431.38.02 <br />Amount <br />Terms of Contract <br />Purpose/Description Opening Bid Date: <br />Amount of El <br />incea <br />se se $ ..................... Deea <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 Original <br />F-1 Jeff Hudak <br />.. ..... . ...... z F1 Terri Swift............................................................ <br />. <br />..... ..... <br />z F-1 Sean Ward <br />