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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/19/16 <br />Name Toy Villa Department Engineering <br />BPW Date 09/13/16 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ® PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Required Information <br />Indiana Earth, Inc. <br />❑ Yes ®No ❑ If Yes <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Corn <br />Demolition of Vacant & Abanc <br />115-117 <br />Blight Elimination <br />210.1060.460.39.82 <br />$ 153,800.00 <br />Project Closeout <br />e VII — Division C <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran. etc. <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />For Change Orders <br />Dispersal After Approval <br />Beth Leonard, Liz <br />Williams <br />1&M <br />Judy Love <br />