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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />10-19-2016 <br />Public Works <br />Engineering <br />BPW Date 10-25-2016 Phone Extension 5903 <br />Kevin Fink <br />Department <br />Division/Bureau <br />I Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <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: Amendment to INDOT Contract <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBEAWBE Contractor 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 />INDOT <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasing <br />El MBE ❑ WBE <br />❑ No ❑ Yes Name of Compan <br />Coquillard Primary Safe Routes to School <br />ENG: 114-066 INDOT: DES# 1400635 <br />Roads and <br />Zb 1-UbU8-38U.10-99 <br />$494,644 <br />80% Federal/ 20% Local <br />Increase contract amount <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />squired For Chanqe Orders Onlv <br />Increase $ 17,005.70 <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />py <br />Original <br />® <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />Nawrot <br />•M <br />After <br />