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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />June 6. 2019 <br />Jeff Hudak <br />Department Central Services <br />BPW Date June 25, 2019 Phone Extension 574-235-9316 <br />�wucrswwsum .o mv!vw:�nrrurxrvu,.�muaesn7u uc— 4-�- - ..—.urvneamssr�wva iem,�r yr��rr ¢ :ww.;AVVMmw-nmrrrv�e����ME ���mulmmrr a�omn�ren,mnadu...�. R��, �. m✓�^�r�,�ew�:�r�:�r+^^+^+wwRfflls„nirmrmnM+�u'),� <br />A <br />Required Prior to Submittal to Board <br />Legal 1Z Attorney Name Clara McDaniels <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing Z Michael Schmidt <br />Check the <br />Agreement <br />El Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑' Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />,ropriate ItemType <br />Contract <br />Resolution <br />® Bid Award <br />❑ Quote Award <br />El C/O &PCANo, <br />Traffic Control <br />!d for All Submissions <br />❑] Proposal <br />El Req. to Advertise <br />❑ PCA <br />Required Information <br />Yes No If Yes <br />MBE WBE <br />Addendum <br />❑ Title Sheet <br />Purchasin <br />❑ No ❑ Yes Name of Compare _ <br />Spec I — One (1) or more 2019 or Newer 18,000 lb. Four Wheel <br />Drive Chassis with Custom Flat Bed <br />200119 Street De artment Le <br />�.. ..._as.e.....Bud.get .....w <br />Principal #202-0607-431-38-01 Interest #202-0607-431-38-02 <br />$ 1"02,840.00 <br />❑ Required Contractor's Certification Form Attached (Non- <br />. ... mmmmmmmmm�m_m_m ollusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. .. - _.._...w._.. _..� <br />R r uire> For Ct Orders Only .�.. ...Wm ... .�.._.... ... <br />Amount of <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />................ <br />Total Percent of Change: <br />Copy Original <br />® ❑ Jeff Hudak <br />® ❑ Terri Swift <br />n Ward <br />Dispersal After Approval <br />