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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />November 30, 2016 <br />Department Community Investment <br />BPW Date December 13, 2016 Phone Extension 5845 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt, Ben Dougherty <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® <br />George King <br />Check the Appropriate Item Type — Required for All Submissions <br />® <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />M <br />Other: <br />I Kequired intormation <br />Company or Vendor Name St. Joseph County Bridges Out of Poverty Inc. <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Yes N No ❑ If Yes, Approved by Purchasing <br />MBE ❑ WBE <br />mployer Resource Network "ERN" <br />404.1001.460.31.06 <br />$ 32,000 originally - Current PO Balance of $20,000 <br />October 13, 2015 - October 31, 2017 <br />Addendum for Extension of Term until October 31, 2017 <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) _ <br />Required For Change Orders Only I <br />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 />Uispersal After Approval <br />Pam Meyer, DCl/UEA <br />Ben Dougherty, Legal <br />