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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 15, 2018 <br />Name Becca Plantz <br />Department Public Works <br />Division/Bureau n Engineerimmmmmm <br />g <br />BPW Date November 27, 2018 Phone Extension 5998 <br />.are immmuwiw wunw.rcaaumrc anz mMIMMIM i <br />......... a _..... ... ._.�.... <br />.._.. _. <br />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 El <br />Check the <br />L J Agreement Amendment <br />Professional Services <br />❑ Bid Opening <br />0 Quote Opening <br />FJ Change Order No. <br />Ease/Encroach. <br />Other: <br />Michael Schmidt <br />oropriate Item Tyo - <br />n Contract <br />❑ Resolution <br />❑ Bid Award <br />® Quote Award <br />El C/O & PCA No, <br />Traffic Control: <br />for All Submissions <br />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Required Information <br />_...._ _...__..... __ _._..... <br />Company or Vendor Name Peerless Midwest <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />New Vendor Purchasing <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 />LJ No J Yes Name of Como y <br />Edison Production Well #2A Rehabilitation <br />118-103 <br />Water ............... ��.............www <br />— ...Wo.rks 0 & M <br />620-0640-602-31-06 <br />' 991.............00....0.... .........w <br />Lump Sum _..............m_ <br />The cleaning and inspection of well #2A at the Edison Filtration <br />Plant. <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />lie red uur' _ <br />..__ .. _ ..._..... ........ _ For C!Ipng� Orders Oral <br />Amount of ❑ Increase $ . <br />0 Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount <br />Total Percent of Change: % <br />Dispersal After Ap roval <br />Copy Original <br />® Becca Plantz _ <br />® El <br />Bradley.�.VanOosterum_�_......................................�.�.�.�.�._ <br />