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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/1/2023 <br />Name Joseph Molnar Department DCI <br />BPW Date 08/08/2023 Phone Extension 6022 <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 />Michael Schmidt <br />Purchasing ❑ <br />Check the Appropriate Item TVDe — Reauired for All Submissions <br />U Professional Services Agreement <br />U Contract <br />U Proposal <br />❑ Open Market Contract <br />❑ Amendment/Addendum <br />❑ Special Purchase, QPA <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Reject Bids/Quotes <br />❑ Proposal Opening <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ Chg. Order, No. <br />❑ Traffic Control <br />❑ Resolution <br />® Other: Environmental <br />❑ Ease./Encroach <br />Restrictive Covenant <br />Required Information <br />Company or Vendor Name <br />City of South Bend Board of Public Works <br />New Vendor <br />❑ Yes❑ If Yes, Approved <br />by Purchasing <br />® No <br />MBE/WBE Contractor <br />❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Project Name <br />Environmental Restrictive Covenant Former Drewrys Brewery <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description Approving of the Environmental Restrictive Covenant for the former <br />Drewrys Brewery at 1408 Elwood. <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 />