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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />December 3, 2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date December 10„ 2019 Phone Extension 574-235-9316 <br />Req.w,,,,,,.,..,,....m,........................,....,,.,.,m,.m.,....eeeea <br />uired. Prior to Submittal to Board ...............................................�.. <br />Legal Attorney Name Clara McDaniels <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller E] and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing <br />Check the P <br />LJ Agreement <br />❑ Professional Services <br />Bid Opening <br />Quote Opening <br />El Chg Order No. <br />El Ease./Encroach. <br />F� Other: <br />Company or Vendor Name <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 />Michael Schmidt <br />Topriate Item Type — <br />El Contract <br />E Amendment <br />® Bid Award <br />El Quote Award <br />0 C/O & PCA No, <br />El Traffic Control <br />for All Submissions <br />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />❑ Resolution <br />f 1 Claim <br />es H If Yes, Approved by Purchasing <br />®LAC <br />Addendum <br />❑ Title Sheet <br />MBE Completed E-Verify Form Attached ❑ Yes <br />WBE ❑ No <br />Spec W — One (1) or More 2019 or Newer 6-Wheeled Motor <br />Grader <br />Street partMent Capital Lease __&.._Interest <br />202-0607-431.38.01 & 202-0607-431.38.02 <br />191,672.00 <br />............... .���.�m.m......._......._................e <br />_..................w... . ... �.�... e or Chi Orders On1�_ �. � � ...................w_�� <br />Amount of Increase _W..........__.. ._. <br />[] Decrease $ <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 <br />Original <br />® <br />Jeff Hudak <br />® <br />E] Terri Swift <br />® <br />El LLSean Ward <br />