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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date March 6, 2018 <br />Name Pam Meyer Department _DCI <br />March 13,2018 <br />BPVV Date Phone Extension 5845 <br />F Required, Prior to Submittal to Board <br />Legal Attorney Name Clara McDaniels <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 F <br />N Agreement <br />H Contract Proposal N Addendum <br />❑ Professional Services <br />F-1 Resolution <br />❑ Bid Opening <br />n Bid Award E] Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />Ej Quote Award <br />❑ Change Order No, <br />❑ C/O & PCA No. F-1 PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />F-1 Other: <br />Company or Vendor Name <br />Selge Construction <br />New Vendor <br />Yes 0 No F-1 If Yes, Approved by Purchasing <br />MBEANBE Contractor <br />MBE F-1 WBE <br />�Project Name <br />N/A <br />�Project Number <br />N/A <br />Funding Source <br />N/A <br />Account No. <br />N/A <br />Amount <br />$0.00 <br />Terms of Contract <br />Purpose/Description <br />To accept donation of transporting 7 modular buildingsfrom Ivy Tech <br />location to a City/Redevelopment location <br />F-1 Required Contractor's Certification Form! Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, IE-Verify, Iran, etc.) <br />Required For Chan ,ge,Orders ,Or1Iy <br />Amount of F-1 increase $ <br />F] Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />'Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />E M Pam Meyer, DCI <br />