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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 17, 2019 <br />Name Jeff Hudak Department Central Services <br />BPW Date September 24, 2019 Phone Extension 574-235-9316 <br />4wvST" Irlr1SuF✓J.:.:nrn,]=��yW,i✓ilWi!%JRPuVN4RIXr'uCrkHSd'/IYO, VIW'VVVVI✓kVMdVUIYF!�6V1/iNN,TNIfr°IYfVNYwma+mAmmmmvmmTm»te YE4Yti"iE'efAAWl11lfd(MiI=�IYIOI�...:.r4nyurv'i'IdM1GC'J,'W'4�SS!!rk7AAAd�IMA'!@IPNIVIW <br />� Required Prior to Submittal Board <br />I to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® George King <br />Check the A <br />Agreement <br />[l Professional Services <br />E] Bid Opening <br />[� Quote Opening <br />E] Change Order No. _ <br />E] Ease/Encroach. <br />0 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBENVBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />riate ltern_Type <br />Contract <br />❑ Resolution <br />® Bid Award <br />❑ Quote Award <br />❑C/O &PCANo. <br />❑ Traffic Control <br />ire ' for All Submissions <br />Required Information <br />Proposal 0 Addendum <br />Req. to Advertise ❑ Title Sheet <br />❑ PCA <br />Yes IL No LJ If Yes, Approved by Purchasi <br />MBE Fl WBE <br />0 No El Yes Name of Com wpy <br />Spec N — One (1) or more 2019 or Newer LP Powered Lift Truck <br />_..019 mmmmmmmmmmEauiDment Services Ca ital Lease Budget <br />605-419-3802 Interest <br />224-0605-419-3801 Principal 224-0 <br />..............e.�.�.�mmmm.�.... .� ................. a ��._.........._._.. <br />$ 31,846.00 <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion Non -Discrimination, Non -Debarments E VerNfy, ar nxwo ow <br />Reg.u.J.re.d.-Fo!Charmge Orders Only <br />Amount of F] Increase $ <br />E] Decrease $ <br />Previous Amount $ <br />Current Percent of Change: %�..._._........................_.,.._�_ <br />�.m.,........_..�.�.�.�.........�.....�.._.... w <br />New Amount $ <br />Total Percent of Change: /o <br />Dispersal After <br />I After Approval <br />Copy Original <br />] �] Jeff Hudak <br />_..........a.....�...._..m.......e...�w...-�m,.............___________ <br />�] M ry Wisniewski <br />0 <br />