Grant Agreement - Crispin Porter & Bogusky LLC - Grant from Dominos for Patching City Potholes

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BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date Name 12/18/18 Jitin Kain Department PW BPW Date 12/20/18 Phone Extension 5835 i eaom'fr�wrmwwu'iimnunrevn:mvt mrumnmmn v u wma imimimimimimimimmmmuuumimiommmmmmmmimimmmnumuuuuuuuuuuuumuluumxo Required Prior to Submittal to Board Legal Attorney Name Clara McDaniels Controller review is required for all Contracts $5,000.00 or more Controller and greater than one year in length per the City Purchasing Policy Purchasing EJ Checkmthe A Agreement ❑ Professional Services Bid Opening El Quote Opening F] Chg Order No. ❑ Ease./Encroach. Other: Company or Vendor Name New Vendor MBE/WBE Contractor Project Name Project Number Funding Source Account No. Amount Terms of Contract Purpose/Description T riate Item Type — [1 Contract El Amendment El Bid Award El Quote Award El C/O &PCANo. _ El Traffic Control for All Submissions Proposal Req. to Advertise PCA [J Resolution n Claim Required Information Crispin Porter & Bo u�sk r LLC Addendum ❑ Title Sheet LJ Yes LJ If Yes, Approved by Purchasing No ❑ MBE Completed E-Verify Form Attached El Yes ❑ WBE ❑ No Domino's Paving for Pizza $5,000 Grant acireement _ __ _ Domino's Pizza has awarded the Cityof South Be n d —ag rant in the amount of $ 5,000 to use towards raatchina Wholes in the city. For Change Orders +91 Amount of Increase $ Decrease $ Previous Amount $ Current Percent of Change: % New Amount $ ..w �.�....___- Total Percent of Change: % _._......... Time Extension: Dispersal Afi6i" Approval Copy Original ❑ ® Crispin Porter & Bugusky ® �I Lind.a....M.a.�.i.n ................_�............. Jitin Kain