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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />8/24/16 <br />Lory Timmer <br />Department DCI <br />BPW Date 9/13/16 Phone Extension 5841 <br />Required Prior to Submittal 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 <br />Check the <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. <br />Ease/Encroach. <br />Other: Amendment <br />Resolution <br />Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control <br />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Company or Vendor Name Historic Preservation Commission of South Bend & St Joseph Co <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name Historic Review of Federally Funded Projects <br />Project Number 16-JC-06 <br />Funding Source Community Development Block Grant (CDBG) <br />Account No. 212.1001.460.39.30 <br />Amount $5,000 <br />Terms of Contract 1/01/16 — 12/31/16 <br />Purpose/Description Increase agency's capacity to complete environmental reviews for <br />the City of South Bend's federally -funded projects <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <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 />❑ <br />❑ <br />Love <br />Dispersal After <br />