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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date June 3, 2019 Department DCI <br />Name Andrew Netter Division/Bureau Plannin <br />g <br />BPW Date 06/11/2019 Phone Extension 5931...-�� <br />t"U�UJ;' ":kYifi�MIMIMIMIMIMIPIPIPNNA I �yVW„�.y�y,;,�,';,'yppp, µSyWINflN�Y 11N 1YYi^s'meee9�W,W,W,W,; �fl�Ifl�IMtl�YMX.v. �'r"*. ipfRIM1XeB rl " NSSQ9R,,, B@ -n.' _� ,�@p„mµryN �Ki'v rr��rswii pry �yp�mµ, .,yry�rydYT�Y n�VVV iYIM1��.s. . �W%�WW"I�WIWIW�MSN_M + FMWA <br />.m . .. Board ........w.� .- w.. �_.. ..w. <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 <br />�..�. �.. Check the_ARro r�� Item ...... � .... �.._ ....._ .._ ...._.... <br />_p w T mmmmm �" gerr for All Submissions <br />X Agreement Amendment .Contract �] Pro osal . .. p �� Addendum <br />❑ Professional Services [� Resolution <br />Bid Opening ® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />EJ Quote Opening ❑ Quote Award <br />Change Order No. El C/O & PCA No. ❑ PCA <br />0 Ease/Encroach. ❑ Traffic Control. <br />F-1 Other: <br />......._... a <br />equired Information_ <br />Company or Vendor Name <br />RosaGonzalez <br />.a <br />.................... ..�. � ........_.. <br />� m.. _ ., n.. <br />EJ Yes No ❑ If Yes, Approved by <br />New Vendor <br />Purchasing ...... <br />MBE/WBE Contractor <br />............... <br />MBE ❑] WBE <br />MBE/WBE Contractor Requested <br />NoYes Name of Com n <br />_.,. . . �.. <br />Project Name <br />_.n_... ... —.... <br />1510 and 1512 Ford St. <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />........ ... .........----_...n. ................... ..-- ..... .._.. .. <br />$1,725 <br />Terms of Contract <br />Purpose/Description <br />Award bid and sign purchase agreement for disposition —of two <br />owned lots: ­11—.111111111510 an d 1512 Ford Wit° South Bend, IN 46628 <br />—r <br />��tRe Required Contractor's Certification Forms Attached Non - <br />q <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />w,W a - <br />Re fired For Change Orders Only w <br />Amount of ❑ increase <br />$ ................. ._ m .._m.. ..........-_.... ....—.....n ....... . <br />0 Decrease <br />-----$ <br />Previous Amount $ <br />..........-- <br />Current Percent of Change: <br />__,..n. .................... ----.. ....... _ — __--- <br />% <br />New Amount $ <br />