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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 10/31/2022 <br />Name: Charlie Brach Department of Public Works – Engineering Division <br />BPW Date: 11/8/2022 Phone Extension: 9246 <br /> <br />Required Prior to Submittal to Board BPW Attorney X Attorney Name <br />Dept. Attorney Attorney Name <br /> <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 /> Other: Ease./Encroach <br />Required Information <br />Company or Vendor Name South Bend Heritage Foundation <br />New Vendor Yes If Yes, Approved by Purchasing <br /> No <br />MBE/WBE Contractor MBE <br /> WBE Completed E-Verify Form Attached Yes <br /> No <br />Project Name Hope Avenue Homes Sewer Extension <br />Project Number DP20-054 <br />Funding Source N/A <br />Account No. N/A <br />Amount N/A <br />Terms of Contract N/A <br />Special Contract Provisions N/A <br />Purpose/Description Project Completion Affidavit for the public sewer extension to serve the New <br />Hope Ave. building development. <br />For Change Orders Only <br />Amount of <br /> <br />Increase <br />Decrease <br />$ <br />($ ) <br />Previous Amount $ <br />Current Percent of Change: <br />Increase <br />Decrease <br /> % <br />( %) <br /> <br />New Amount $ <br />Total Percent of Change: <br />Increase <br />Decrease <br /> % <br />( %) <br /> <br />Time Extension Amount: <br />New Completion Date: <br />