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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />7/10117 <br />Jeff Hudak <br />Department Central Services <br />U <br />Agreement <br />U Contract LJ Proposal U Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />f lOther: <br />Company or Vendor Name <br />New Vendor <br />MBEAVBE Contractor <br />MBEAVBE 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 />U Yes L.J No U If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Spec W — One (1) or more 2017 or Newer Single Axle Dump Truck <br />with Underbody Scraper <br />2017 Venues, Parks, & Arts Capital Principal 201-1101-452-37-11 & <br />Interest 201-1101-452-37-12 tsubiect to lease funding) <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <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 />❑ <br />® <br />❑ <br />Dispersal After Approval <br />Jeff Hudak & Sheila Enos <br />Paul Moreland, Aaron Perri, Cecil Eastman <br />