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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 16, 2016 <br />Name <br />Roger Nawrot <br />Department <br />Engineering <br />BPW Date <br />December21, 2016 <br />Phone Extension <br />5932 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller El <br />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 />greater <br />Purchasing ❑ <br />George King <br />Check the Appropriate <br />Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ <br />Contract ❑ Proposal ❑Addendum <br />❑ <br />Professional Services <br />❑ <br />Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control <br />® <br />Other: PSA Amendment No. <br />1 <br />Reauired Information <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 />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Origin <br />® <br />❑ <br />El <br />DLZ Indiana, LLC <br />❑ Yes ® No <br />❑ No ❑ Yes Name of Company <br />Emeraencv Repair of Ireland Road at High Street <br />COIT <br />404-0608-431.36-10 <br />$2,805.00 Total Amount of the Agreement $20,235.00 <br />Not to Exceed <br />There were plan and specification changes made to bid <br />documents after they were completed by the City. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Nawrot <br />