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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 30, 2019 <br />Name Roaer Nawrot <br />Department Public Works <br />BPW Date October 8,2019 Phone Extension 5932 <br />i�imuwwwmuw�umwummm�uw �wu�www iwm� ar:�wm��!�wwwir.Hww�wmuw�a � �mamsw�mmimmm;�w�arum w�ummommmmm�aawummnmm ;�;�iummwm!mu <br />_. <br />Submittal to Board Re �,u�rPrior to Sed _�� ..............�............._. <br />Legal Attorney <br />Clara McDaniels <br />Controller E] Controller review is required for all Contracts $5,000.00 or more anc <br />greater than one year in length per the City Purchasing Policy <br />Purchasing !, <br />Check the A <br />LJ Agreement <br />Professional Services <br />❑ Bid Opening <br />Quote Opening <br />( Change Order No. <br />Ease/Encroach. <br />Other: Amendment #3 <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 />rrrriat Item Types —fit <br />❑ Contract <br />❑ Resolution <br />El Bid Award <br />El Quote Award <br />l C/O & PCA No. <br />❑ Traffic Control <br />fired" for All Submissions <br />Proposalmmmmm m w <br />Required Information <br />DLZ Indiana, LLC <br />[� Yes No <br />7MBE I I WBE <br />Req. to Advertise <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />If Yes, Approved by Purchasin <br />Stakinq right of wav and inspecting utilitv relocation before the stree <br />reconstruction contract is awarded by INDOT and services durina <br />construction. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Vrifv, Iran„ etc.) <br />equired For Change Orders On <br />Amount of Increase $ <br />Decrease <br />Previous Amount $ <br />Current Percent of Change - <br />New Amount $ <br />Total Percent of Change:� <br />Dispersal After Approval <br />Copy <br />Original <br />11 <br />❑ <br />El <br />❑ <br />0 <br />❑ <br />