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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date _04/24/2019 <br />Name To V �__..... <br />y v. <br />ills Department Engineering <br />BPW Date 05/14/2019 Phone Extension 5920 <br />affil !TGIF N WWWWWWWIWWNWN I'�WVWV�IWVIVIVIVIVW00 Ml�ld <br />. .m............. ....... W.....�� ................... wuW. m.�..m......,. �,..............��........�,�,.....m....,.,.�.�.., w,.... <br />w w Required Prior to Submittal to Board <br />......._ _ ............... .. - _.....--........ — .....-v .-........-.--------- <br />Legal E] Attorney Name <br />Controller Controller review is required for all Contracts $5,000.00 or more anc <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the <br />LJI Agreement <br />El Professional Services <br />Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />El Ease/Encroach. <br />E] Other: <br />)ro riate Item T O e ire for All Submissions <br />Contract _.. �... ......._..-......... <br />I� E] Proposal C Addendum <br />El Resolution <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />Quote Award <br />El C/O & PCA No. ® PCA <br />❑] Traffic Control <br />Required Information <br />Company or Vendor Name Martell Electric, LLC <br />New Vendor ❑ Yes Ell No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE []I WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Project Number 1.1 ..,.,.......� Riverside Li c hting .m._.. <br />ht U South Bend - <br />Funding Source COIT <br />Account No. 404.0602.431.31.06 <br />Amount $103,189.20 <br />Terms of Contract <br />Purpose/Description Project Closeout <br />-❑ Required Contractor's Certification Form Attached (Non - <br />Collusion„ Non -Discrimination, Non -Debarment, E-Verif, Iran, etc. <br />uired For Change Orders On <br />Amount of El Increase $ <br />❑ Decrease ...$ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy <br />Original <br />11 <br />F] <br />0 <br />El <br />