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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />March 21, 2017 <br />David Relos <br />Department DCI <br />BPW Date March 28, 2017 Phone Extension 5836 <br />Legal ❑ Attorney Name Michael Schmidt <br />Controller El greater <br />review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />C'hark tha Annrnnriata Itam Tvna — Ranuirarl fnr A/1 Ruhmiccinn.c <br />ILI Agreement " Contract LJ Proposal U Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Required Information <br />Company or Vendor Name Paul & Mari Chamberlin <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />I Yes ❑ No ❑ If Yes, Approved by Purchasing <br />] MBE ❑ WBE <br />Fire Station # 9 <br />EMS Operating <br />287-0902-422-42-01 <br />$ 85,000 <br />Purchase Agreement & Uniform Acquistion Offer <br />Acquisition of property at 2112 Mishawaka Ave. <br />❑ Required Contractor's Certification Form Attached (Non - <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 />or <br />Dispersal After Approval <br />Michael Schmidt <br />David Relos (for closing) <br />