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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10-23-20 <br />Name Kim Thompson Department Utilities <br />BPW Date 10/27/20 Phone Extension 5969 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney <br />® Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Clara McDaniels <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required. for All Submissions <br />Professional Services Agreement ❑ Contract ❑ Proposal <br />❑ Open Market Contract ❑ Amendment/Addendum ❑ Special Purchase, QPA <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes <br />❑ Proposal Opening ❑ C/O & PCA No. ❑ PCA <br />❑ Chg. Order, No. ❑ Traffic Control ❑ Resolution <br />® ❑ Ease./Encroach <br />Other: <br />Required Information <br />Company or Vendor Name St. Joseph County Regional Water and Sewer District <br />New Vendor ❑ Yes❑ If Yes, Approved by Purchasing <br />❑ No <br />MBE/WBE Contractor ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />N/A <br />Asset Purchase Agreement for Carriage Hills sewer <br />extension <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount $ <br />Increase % <br />Current Percent of Change: Decrease ( %) <br />New Amount $ <br />Increase % <br />Total Percent of Change: Decrease ( %) <br />Time Extension Amount: <br />New Completion Date: <br />