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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/19/16 <br />Name Toy Villa /4 Department Engineering <br />BPW Date 09/23/16 Phone Extension 5920 <br />I <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />® C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of ❑ Increa <br />® Decree <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />Required Information <br />Indiana Earth, Inc. <br />❑ Yes ®No ❑ If Yes <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Com <br />Demolition of Vacant & Abanc <br />115-117 <br />1060.460.39.82 <br />VII — <br />Approval of Change Order #4 & Completion Affidavit <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc <br />For Change Orders <br />Z.3b% <br />$ 186,898.00 <br />4.47% <br />Dispersal After Approval <br />Beth Leonard, Liz Maradik, Judy Love <br />Toy Villa <br />