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Date 10-31-16 <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department Public Works <br />Name <br />Kevin Fink <br />Division/Bureau <br />Engineering <br />BPW Date <br />11-08-16 <br />Phone Extension <br />5903 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Checkthe, <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Item Type — <br />Resolution <br />Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control: <br />Inform <br />Abonmarche i <br />❑ Yes ® No <br />❑ MBE ❑W <br />I -I No F- Yes <br />Center <br />116-079 <br />River East TIF <br />429-1050-460.42-03 <br />$ 86,200.00 <br />80/20 Match with INDOT <br />?d for All Submission. <br />❑ Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />Inc. <br />❑ If Yes, Approves <br />:ompany <br />e Routes to School <br />Addendum <br />❑ Title Sheet <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />uired For Change Orders <br />Amount of ❑ 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 />❑ Roger Nawrot <br />® <br />❑ Kevin Fink <br />