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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />5/20/2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date 5/28/2019 Phone Extension 574-235-9316 <br />n�nMw+raviru�muRiririRiRURURURu�ww�u�u���u�u�nwxvr�nw�nivwMi��x✓,.n,. ,.. .�rr�nwximm�rni�. � :.�e+�x—..:�ms, suov,�uaa.:... av�krrarrar��rr✓eeexmawwir.�m�, ���r;- :.�—,wra.�,ux^����uwuueaaum <br />Required Prior to Subm <br />ittal to Board <br />Legal <br />Attorney Name Clara McDaniels <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ <br />and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ® <br />Michael Schmidt <br />... ....... ,_._ ................ <br />Check the Appropriate Item Type Required for All Submissions <br />0 Agreement <br />EI Contract E Proposal 1 Addendum <br />❑ Professional Services <br />❑ Amendment <br />❑ Bid Opening <br />® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Chg Order No. <br />[] C/O & PCA No. <br />PCA <br />❑ Ease./Encroach. <br />❑ Traffic Control <br />Resolution <br />[� Other: <br />❑ <br />Claim <br />Required Information. <br />Company or Vendor Name„m <br />New Vendor <br />�.....s....................... � If Yes, Approved by P ............................. <br />Purchasing �.._...,,,_...e.,��.................._ <br />No <br />MBE/WBE Contractor <br />❑❑ WBE Completed E-Verify Form Attached El Nos <br />Spec D — One (1) or More 2018 or Newer Truck Mounted <br />Project Name <br />Automatic Pothole Patcher <br />Project Number <br />..........�.. ....................._�......_� _.__......��,,,,,.....--------- ..................... ...�......�re...- <br />Funding Source <br />2019 Capital Lease Principal & Interest (Street Department) <br />Account No. <br />-202-0607-431-38-01 I-202-0607-4 <br />_P--- ...... <br />0 <br />Terms of Contract <br />Purpose/Description <br />Forhane Orders On.l. <br />Amount of El increase <br />.........................................................................._ <br />Decrease....$ <br />Previous Amount $ <br />Current Percent of Change: <br />% <br />New Amount $ <br />Total Percent of Change: <br />%..............w.. _mm.� <br />......... <br />Time Extension: <br />.. <br />Dispersal After Approval <br />pp I <br />Copy Original <br />® Jeff Hudak <br />® ................ <br />I❑ Terri Swift <br />nm_..................................�.... <br />� ❑ ............ <br />SeanWard <br />