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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 3/21/2023 <br />Name: Charlie Brach Department of Public Works – Engineering Division <br />BPW Date: 4/11/2023 Phone Extension: 9246 <br /> <br />Required Prior to Submittal to Board BPW Attorney X Attorney Name Michael Schmidt <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: Deed of Dedication Ease./Encroach <br />Required Information <br />Company or Vendor Name 806 Sample South Bend LLC <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 806 Sample Deed of Dedication <br />Project Number DP22-039 <br />Funding Source N/A <br />Account No. PR/PO # N/A <br />Amount N/A <br />Terms of Contract N/A <br />Special Contract Provisions N/A <br />Purpose/Description Deed of Dedication to dedicate ROW along the frontages of the property <br />located at 806 Sample. This will dedicate the ROW for the new tree lawn and <br />sidewalk being constructed as part of the redevelopment of the parcel. <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 />