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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 15, 2016 <br />Name Michael Divita Department DCI <br />BPW Date November 22, 2016 Phone Extension 5843 <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 />Company or Vendor Name <br />Urban Enterprise Association of South Bend Inc. <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBEM/BE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />West Side Main Streets Matching Grant Program <br />Project Number <br />Funding Source <br />COIT <br />Account No. <br />404.1001.460.39.30 / 16JXO1 <br />Amount <br />$50,000 <br />Terms of Contract <br />Purpose/Description <br />Provide extension and additional funding for facade matching grant <br />program for Lincolnway West and Western Avenue <br />❑ Required Contractor's Certification Form Attached (Non- <br />_ _ <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 />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />❑ ® Michael Divita (for Community Investment) <br />❑ ® Michael Divita (for UEA) <br />❑ ❑ <br />