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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date June 3, 2019 Department DCI <br />­ � . . ........ .... . . . ..................... -- - -- -------- <br />Name Andrew Netter Division/Bureau Planning <br />BPW Date 06/11/2019 Phone Extension 5931 <br />- ----- ....... <br />.. . . ....... <br />Req red Prior to Submittal to Board <br />- - ---_,_� ­_____ . ... . .................... <br />Legal FA Attorney Name: Clara McDaniels <br />Controller El Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing 0 <br />Checkthe <br />El Agreement Amendment <br />F-1 Professional Services <br />F] Bid Opening <br />F-1 Quote Opening <br />Change Order No. <br />❑ Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />Terms of Contract <br />iropriate Item Type - <br />Contract <br />F-1 Resolution <br />El Bid Award <br />Ej Quote Award <br />n C/O & PCA No. <br />F-1 Traffic Control: <br />Required Information <br />for All Submissions <br />Proposal <br />Z Req. to Advertise <br />F1 PCA <br />U310-Tarly or, <br />El Title Sheet <br />Purpose/Description Request to advertise sale of City owned property: 1421 N, <br />Medora Sk�South Bend, IN 46628 <br />". ., ­­ .... . ......... . . ............... . ... . .... . . . . . ................... . ...... <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />#q �­_­­ ...... <br />...... ...... ... y!!ed _Flor C.han e Orders Onily <br />F-1 Amount of increase $ <br />.... . ..... ------ .......... <br />F] Decrease $ WWAS <br />Previous Amount $ <br />---- -------- <br />Current Percent of Change: <br />New Amount $ <br />..................... I'll ..... <br />Total Percent of Change - <br />Copy Original <br />M F] Andrew Netter <br />Ej El <br />Dispersal After Approval <br />