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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />1 /30/17 <br />Lory Timmer Department <br />DC] <br />BPW Date 2/14/17 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: Amendment <br />Required Information <br />Company or Vendor Name Habitat for Humanity of St. Joseph Co., 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 <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />/ Rehab — 10 19 Thomas Street <br />16-JC-11 <br />CDBG <br />212.1001.460.39.30 <br />103,000 <br />1/01/17— 12/31/18 <br />Purpose/Description Salaries related to coordinatinq Neighborhood Leadership Academy <br />and neighborhood technical assistance <br />® Required Contractor's Certification Form 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 />® ❑ Judy Love <br />❑ ❑ <br />11 ❑ <br />