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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date January 31, 2017 Department <br />Name Toy Villa -- Division/Bureau <br />BPW Date February 14, 2017 Phone Extension <br />Public Works <br />Engineering <br />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. 1 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />❑ Other: <br />Required Information <br />Company or Vendor Name Michiana Contracting, Inc. <br />❑ Yes XI No I-1 If Yes. ADDroved by <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 />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Olive Road Lighting over the Indiana Toll Road <br />115-124 <br />COIT <br />404.0602.431.31.06 <br />Approval of C.O.#1 for extra wiring <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Reauired For Chanae Orders Onlv <br />Increase $ 4,119.00 <br />Decrease $ <br />