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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 02/17/17 <br />Name <br />Toy Villa <br />Department <br />Engineering <br />BPW Date <br />02/28/17 <br />Phone Extension <br />5920 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name <br />Controller El greater <br />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. 11 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />I 1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <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 />Required Information <br />Reith Riley Construction Co., Inc. <br />Yes ® No ❑ If Yes, Ap <br />F] MBE I-1 WBE <br />No ❑ Yes Name of Com <br />Pu <br />South Bend One Wav to Two Wav Conversion — Division B <br />Approval of Change Order #11 <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 />® Increase $ 33,133.07 <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 />® <br />❑ <br />$ 17,505,247.68 <br />0.19% <br />$ 17,538,380.75 <br />8.72% <br />Michael Divita <br />Toy Villa <br />Dispersal After Approval <br />Love <br />