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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />May 20, 2019 <br />Jeff Hudak <br />Department Central Services <br />Extension � <br />B Date May 28 2019Pr�u�u��Phone Extension574 235-9316 <br />Required..� Prior to SubmittalBoard......_d- <br />..., to ...�....�_....� <br />Legal E Attorney Name Clara McDanels <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 />LI Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />Change Order No. _ <br />Ij Ease/Encroach. <br />I❑ 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 Read <br />❑ Contract ~....... <br />Resolution <br />;; Bid Award <br />El Quote Award <br />0 C/O & PCA No, <br />❑ Traffic Control <br />or All Submissions <br />] Proposal <br />❑ Req. to Advertise <br />Required Information <br />No ❑ If Ye____ <br />es, <br />E WBE <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />by Purchasin <br />El <br />o es Name of Company <br />Spec J — One (1) or More 2019 or Newer Front Wheel Dri v e Cargo <br />Van <br />2019 Wa <br />ter Works Capital Budget <br />622-064.... -4..... <br />02 <br />$28,384.00 <br />❑ Required Contractor's Certification form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment„ E-Verify, Iran, etc. <br />_..... _� ....r ....... <br />- Rectuir d For Change Orders Onlymmm <br />Amount of Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />