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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/28/2016 Department Public Works <br />Name Richard Estes Division/Bureau Engineering <br />BPW Date 11/8/2016 Phone Extension 5896 <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 ® George King <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 />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Lawson -Fisher Associates <br />❑ Yes ® No ❑ If Yes, Approved by <br />LJ MBE U WBE <br />❑ No ❑ Yes Name of Company <br />South Bend Dam, West Race Reoairs <br />5-11 <br />101-0602-431.31-06,7304-42010-0000-0099 <br />19, 600.00 <br />Tax <br />Terms of Contract Complete 60 days from NTP <br />Purpose/Description Inspect existing conditions and prepare construction drawings <br />for the repair of the radial gate and the stoplogs at the west race <br />of the South Bend Dam. <br />❑ Required Contractor's Certification Forms 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 />Dispersal After Approval <br />Copy Original <br />® ❑ Patrick Kerr <br />® ❑ Sky Medors (LFA) <br />® ❑ Eric Horvath <br />