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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date June 17, 2019 <br />Name Jeff Hudak <br />Department Central Services <br />BPW Date June 25, 2019 Phone Extension 574-235-9316 <br />�k3a_�fssa r,r5�'r2:: ��r;c',,;-�isw.o�✓.tvc+.mz�,cri wvr�a:,ao�z„v:',�Ui...kR.�?vuu&L'v?k�'.'L'�SAS!'�'sSi:FtlslR�'t9. Afln.✓iYNffiMIA.�iM1ItlW�T.ffv�C2ISC�rTM�',ri".n*�kf.v"'v�vfP..w2;'qmlW"lElA"l�AW99NfI010N1A:�'iWW.'WX'.ffiWWYh'Yifr,1:�'k�&Rdl+.l�k1+MCf"M'ir i5„u, Irfush.XSRf�.��+fiT. L-M9.rL'tl,'ZWI� <br />.... _. _..,..,,,. ......... ... __ ,,....... �.,�.,....... <br />... Required Prior to Submittal to Board _---------- ........ <br />Legal ® Attorney Name Michael Schmidt <br />Controller El 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 George King <br />Check the <br />LAgreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. _ <br />❑ Ease/Encroach. <br />F� 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 />iropriate Item Type — <br />E Contract <br />❑ Resolution <br />❑ Bid Award <br />Quote Award <br />�jC/O &PCANo. <br />— <br />Traffic Control <br />for A11 Submissions <br />] Proposal <br />® Req. to Advertise <br />Required Information <br />❑ PCA <br />No ... .......www <br />If Yes, Approved by Purchasi <br />WBE <br />Addendum <br />❑ Title Sheet <br />Name of any <br />,wNo❑ Yes Comp�._...____.. <br />Spec P — One (1) or More 2019 or Newer Truck Mounted Street <br />Sweeper <br />2019 Street........D...e artment Capital Lease & Interest _ Lease 612-1201-415.38.01 Interest 612-1201-415.38.02 <br />Bid Opening Date: July 23, 2019 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, 4Non-Discrimmination, Non -Debarment, E Verify, Iran, etc. <br />Red fireFir ChanTe Orden Orly <br />- - <br />Amount of c� Increase $ <br />[� Decrease $ <br />Previous Amount $ <br />Current Percent of Change. <br />New Amount $ <br />Total Percent of Change: <br />................ <br />Copy Original <br />® Jeff Hudak <br />® Terri Swift <br />ft <br />® ❑ Sean ......... Ward <br />Dispersal After Approval <br />