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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />8/16/2016 <br />Richard Estes <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 8/23/2016 Phone Extension 5896 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ® <br />George King <br />Check the Appropriate Item Type <br />— Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract <br />❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />® Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />I-1 <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />HRP Construction Inc. <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />RWDA TIF <br />324-1050-460.31-02 <br />New road in the Ameriplex Site between Brick and Adams Road. <br />Including sanitary, water main, storm sewer, and lighting. Award <br />subject to additional funds being provide by the South Bend <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Copy <br />Original <br />® <br />❑ <br />Nawrot <br />Paul Phair (Holladay Properties) <br />