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Date <br />Name <br />BPW Date <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />5/10/18 <br />Jeff Hudak <br />5/22/18 <br />Department Central Services <br />Phone Extension 574-235-9316 <br />--Required Prior to Submittal to Board <br />Legal Z Attorney Name Clara M,cDaniels <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing Z Michael Schmidt <br />Check the Appropriate <br />Item Type — Required for All Submissions I <br />Agreement <br />...... . ... . .... .... <br />n Contract El Proposal Addendum <br />F-1 Professional Services <br />0 Resolution <br />n Bid Opening <br />❑ Bid Award Req. to Advertise E] Title Sheet <br />F1 Quote Opening <br />❑ Quote Award <br />❑i Change Order No. <br />F-1 C/O & PCA No. Ej PCA <br />E] Ease/Encroach. <br />El Traffic Control <br />El Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />0 YesEl INo El If Yes, Approved by Purchasing <br />MBEANB,E Contractor <br />❑ MBE [:1 WBE <br />MBEANBE Contractor <br />Requested <br />El NoEl Yes Name of Company, <br />Spec R — One (1) or more 2018 or Newer Combination Jet <br />Project Name <br />RodderNacuum Machine with Cab & Chassis <br />Project Number <br />2018 Sewer Department Capital Budget <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Bid Opening Date: <br />n Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <br />Amount of <br />F-1 Increase $ UP <br />VID <br />El Decrease $ Ptlilqu wo-as- <br />Previous Amount $ <br />Current Percent of Change: % MAY 9 o 9CHA I <br />New Amount <br />Total Percent of Change: W&C <br />Dispersal After Approval <br />Copy <br />Jeff Hudak <br />Derick Roberts, Dale Helpingstine, Terri Swift <br />Original <br />M <br />F-1 <br />z <br />n <br />F-1 <br />El <br />