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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 5, 2019 <br />Name Toy Villa Public Works — Eng. <br />BPW Date November 12 2019 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />BPW Attorney Attorney Name <br />Dept. Attorney EJ Attorney Name <br />Purchasing <br />Check the Ap rya riat Item lii°d i°All Submissions <br />Professional Services Agreement 0 Contract Proposal <br />Open Market Contract Amendment/Addendum ❑ Special Purchase, QPA <br />E] Bid Opening Bid Award 0 Req. to Advertise ❑ Title Sheet <br />R Quote Opening 0 Quote Award ❑ Reject Bids/Quotes <br />E] Proposal Opening n C/O & PCA No. ® PCA <br />] Chg. Order, No. E] Traffic Control ❑ Resolution <br />Other: Ease./Encroach <br />Required Information <br />Company or Vendor Name Michiana Contracting, Inc. <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />El Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />❑ MBE Completed E-Verify Form Attached El Yes <br />❑ WBE F] No <br />School Zone Flashin-2. Beacon Relocations <br />119-058 <br />LRSA Capital <br />251.0608.431.42.96 <br />....._.__ <br />$9.800.00 <br />Project <br />Closeout <br />For Change Orders Onl <br />Amount of <br />Increase $ <br />❑ <br />Decrease $ ) <br />Previous Amount <br />$ <br />................. _...._. <br />Increase <br />% ............ .--- <br />Current Percent of Change: <br />Decrease <br />............. <br />�% <br />New Amount <br />$ <br />................w._._. <br />Increase <br />o <br />/o <br />....._.. ....._. <br />Total Percent of Change: <br />Decrease <br />Time Extension Amount: <br />New Completion Date: <br />........ ............ <br />