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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: <br />Name: <br />3/18/2025 <br />Gemma Stanton <br />Department of Public Works — Engineering Division <br />BPW Date: 3/25/2025 Phone Extension: 9083 <br />Required Prior to Submittal to Board Is <br />BPW Attorney X Attorney Name Michael Schmidt <br />Dept. Attorney ❑ Attorney Name <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: Addition to a ❑ Ease./Encroach <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Special Contract Provisions <br />Purpose/Description <br />Amount of ❑ <br />El <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Information <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />E] MBE <br />❑ WBE Completed E-Verify Form Attached ❑ Nos <br />Add a water service area to the extension areas shown in Resolution 17-2021 <br />Increase <br />Decrease <br />In <br />DI <br />In <br />Total Percent of Change: DI <br />Time Extension Amount: <br />New Completion Date: <br />CITY OF SOUTH BEND, INDIANA <br />BOARD OF PUBLIC WORKS <br />Elizabeth A. Maradik, President <br />Gary A. Gilot, Member <br />Murray L. Miller, Member <br />Joseph R. Molnar, Vice President <br />Breana Micou, Member <br />r�-14 <br />Attest: Theresa M. Heffner, Clerk <br />Date: March 25. 2025 <br />