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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date2/4/.1.9 _...................................................... <br />Name Jeff Hudak Department Central Services <br />BPW Date 2/12/19 Phone Extension 574-235-9316 <br />Required m� Board <br />...... ... Prior to Submittal to Boa._ <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 ® Michael Schmidt <br />Check the <br />❑' Agreement <br />El Professional Services <br />Bid Opening <br />Quote Opening <br />] Change Order No. <br />[l Ease/Encroach. <br />n Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE 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 />rropriate Item Type— <br />El Contract <br />F1 Resolution <br />Bid Award <br />® Quote Award <br />❑ C/O &PCANo. <br />_ <br />❑ Traffic Control <br />for All Submissions <br />....�.......................�.. ... .... <br />Prop.� Adde <br />ndum <br />endum <br />❑ Req. to Advertise ❑ Title Sheet <br />Required Information <br />Yard N Gard <br />11 .... Y-es- F T No <br />II MBE WBE <br />❑ PCA <br />If Yes, Approved by Purchas <br />No ❑ Yes Name of Company <br />Ratify Quote Award Grand Stand Multi Force with 60 Deck <br />2016 Eument Lease Proceeds <br />�... _M �. <br />201-1101-452-4302 <br />$32,277.98 <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment„ E Verify, Iran,4 etc. <br />Required For Change Orders Only <br />Amount of F] Increase $ <br />Decrease $ <br />Previous Amount <br />....................... <br />Current Percent of Change: <br />New Amount$ <br />Total Percent of Change: ............... <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ Jeff Hudak <br />................................� <br />❑ <br />❑ <br />