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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/06/17 <br />Name Toy Villa Department Engineering <br />BP\N Date 12/12/17 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal F-1 Attorney Name <br />Controller El Controller review is required for all Contracts $5,0010.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing 1:1 <br />" Agreement <br />E] Professional Services <br />El Bid Opening <br />n Quote Opening <br />Change Order No. 16 <br />❑ Ease/Encroach. <br />F-1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBENVBE Contractor <br />MBEANBE 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 />H Contract L] Proposal H Addendum <br />F-1 Resolution <br />0 Bid Award El Req. to Advertise ❑ Title Sheet <br />F-1 Quote Award <br />F] C/0 & PCA No. E] PCA <br />n Traffic Control <br />Reich Riley Construction Co., Inc. _ <br />El Yes 0 No El If Yes, Approved by Purchasing <br />F1 MBE n WBE <br />El No 0 Yes Name of Company <br />South Bend One Way to Two Way Conversion — Division B <br />116-001 <br />Special LOIT <br />257.0608.431,42.96 <br />Approval of Change Order #16 <br />F-1 Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <br />Amount of H Increase $41,040.00 <br />El Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />F-1 <br />F-11 <br />1:1 <br />R <br />El <br />El <br />$ 17,729,582.55 <br />0.23% <br />$ 17,770,622,55 <br />10.16% <br />Dispersal After Approval <br />