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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date March 16, 2017 <br />Name Pam Meyer Department DCI <br />March 28, 2017 <br />BPW Date Phone Extension 5845 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt, <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ® Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />I-1 Other: <br />Required Information <br />Company or Vendor Name Rebuilding Together, St. Joseph County Inc. <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Yes N No U If Yes, Approved by Purchasing <br />MBE F WBE <br />Homeowner Rehabilitation <br />CDBG Funds <br />Fund 212 <br />$ 150,000 <br />January 1, 2017 - December 31, 2017 <br />Housing repair costs for no less than 13 low and moderate income <br />homeowners. <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc <br />ired For Chanqe Orders <br />Amount of H 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 />❑ <br />❑ <br />Dispersal After Approval <br />Pam Meyer, DCI <br />