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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />11/4/19 <br />Matt Chlebowski <br />Department Central Services <br />BPW Date 11/12/19 Phone Extension 574-235-9316 <br />mall <br />Re uired Prior to Submittal to Board <br />. .......... <br />Legal Attorney Name Clara McDaniels <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller Z and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing Z <br />Check the A <br />D� Agreement <br />El' Professional Services <br />E:1 Bid Opening <br />F-1 Quote Opening <br />F-1 Chg Order No. <br />F-1 Ease./Encroach. <br />R Other: <br />Company or Vendor Name <br />New Vendor <br />MBENVBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Michael Schmidt <br />iropriate Item TypE <br />El Contract <br />ElAmendment <br />El Bid Award <br />F, Quote Award <br />El C/O & PCA No <br />0 Traffic Control <br />Re <br />CC G Sy§l <br />0"Yes <br />No <br />MBE <br />WBE <br />General A <br />=Required for All Submissions <br />Proposal <br />El Req. to Advertise <br />[:1 PCA <br />El Resolution <br />F-1 Claim <br />ui.red Information -- - ------ - ------ --------- - M§Jnc, dba FASTER Asset Solutions <br />❑ If Yes, Approved by Purchasing <br />Completed E-Verify Form Attached <br />reement with FASTER <br />Central Services C <br />... ................................ -- __a!F <br />224-0605-419.43-08 <br />$225,989---- <br />Renewabley arly <br />Opening Bid Date, <br />Fund <br />For Change Orders Only <br />--"" .... . .. ..... . ...... .. . . . . . . ..... <br />Amount of El increase $ m <br />---- - ---- - - 0 Decrease <br />Previous Amount <br />Current Percent of Change: % <br />New Amount t <br />. . . ................. . ...... <br />Total Percent of Change: % <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />z <br />r-1 Matt Chlebowski <br />z <br />F-1 Matt Coats <br />z <br />El Dan O'Connor <br />Addendum <br />El Title Sheet <br />El Yes <br />El No <br />