ࡱ > A D @ g * bjbj)) 4, xCy\xCy\$ l l d > t ( 0 = Y U W W W W W W $ { i ^ i i { l l i " l R U i U " u 8 " A 0 V 0 V V P i i i i i i i { { i i i i i i i V i i i i i i i i i > 2 : ENGINEERING SERVICES REQUEST FORM Please answer all questions, be complete and specific with responses. Send completed form to the City of Topeka Engineering Division, 620 S.E. Madison, 2nd Floor, Topeka, Kansas 66607, Attn: Brian Faust. REQUESTING DEPARTMENT/DIVISION:CONTACT PERSON: SCOPE OF PROJECT: (Be specific) SOURCE OF FUNDS: (Check one) FORMCHECKBOX Capital Improvement Program Year: ______________ FORMCHECKBOX Operating Budget Funds Line Item No.: ______________________________________________ FORMCHECKBOX Other: ESTIMATED PROJECT COST:(Note: Amount shown should include costs for Construction, Construction Inspection, Design, Administrative Fees, Land Acquisition and Interim Financing Costs.) PROJECT SCHEDULE: Task Planned Start Date Planned End Date Planning Design Constr. Completed SUPPLEMENTAL INFORMATION: (Any work done previously, project location, etc.) SIGNATURE: ________________________________ ______________________ Department/Division Head Date ************************************************************************************************** Project and Engineering Services Request is approved for assignment: Brian Faust, City EngineerDate Project Number:Project Engineer: ! " ( ) ; O P a m n | } ~ * + , 5 6 7 Q ׯעׯוׯxrlf hK CJ hcZL CJ h