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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />12/15/16 <br />1iP=MI <br />Department DCI <br />BPW Date 12/27/16 Phone Extension 5841 <br />Required Priar 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 />❑ <br />Agreement N <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 />Other: Amendment <br />Company or Vendor Name La Casa de Amistad, Inc. <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name La Casa de Amistad Food Pantry ADA Improvements <br />Project Number 16-JC-01 <br />Funding Source CDBG <br />Account No. 212.1001.460.39.30 <br />Amount $ 36,000 <br />Terms of Contract 1101116 — 12/31/17 <br />Purpose/Description Rehab of the La Casa de Amistad food pantry to improve ADA <br />accessibility <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />,�equrr`�d IT�r, �C�nge, Orders Qrrly <br />Amount of ❑ 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 />❑ Judy Love <br />❑ <br />❑ <br />❑ <br />❑ <br />