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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />9/13/16 <br />Lory Timmer <br />Department DCI <br />BPW Date 9/27/16 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 Appropriate Item Type — Required for All Submissions <br />❑ Agreement ® Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Required Information <br />Company or Vendor Name Near Northwest Neighborhood Inc. <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE — <br />MBENVBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name Acquisition/Rehab Activity — 725 Harrison Ave <br />Project Number 16-JC-23 <br />Funding Source Community Development Block Grant (CDBG) <br />Account No. 212.1001.460.39.30 <br />Amount $184,500 (no change in contract amount) <br />Terms of Contract 1/01/16 — 12/31/17 <br />Purpose/Description Acquire and rehab house at 725 Harrison Ave for resale to low -mod <br />income buyer <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Chanqe Orders Only <br />Amount of LJ 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 />rsal After Approval <br />