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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 09/20/16 <br />Name Toy Villa Department Engineering <br />BPW Date 09/27/16 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name <br />Michael Schmidt <br />Controller ❑ <br />Controller review is <br />required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type <br />— Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract <br />❑Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />® <br />Change Order No. 5 <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />Fl <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Required Information <br />Reith Riley Construction Co., Inc. <br />Yes No ❑ If Yes, Ap <br />❑ MBE Fl WBE <br />No ❑ Yes Name of <br />South Bend One Way to Two Way Conversion — Division A <br />116-001 <br />SSDA TIF <br />430.1050.460.31.36 <br />Approval of Change Order #5 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination. Non -Debarment_ F-Verifv Iran Mi <br />I Required For Chance Orders Only I <br />Amount of <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />2.46ulo <br />$ 3,435,946.47 <br />6.43% <br />Dispersal After <br />Michael Divita <br />Leonard, Judv Love <br />