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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/15/16 <br />Name <br />Toy Villa <br />Department <br />Engineering <br />BPW Date <br />08/23/16 <br />Phone Extension <br />5920 <br />L 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 />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />® Change Order No. 5 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Required Information <br />Reith Riley Construction Co., Inc. <br />Yes ®No ❑ If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />South Bend One Way to Two Way Conversion — Division B <br />116-001 <br />2015 TIF <br />Approval of Change Order #5 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion Non -Discrimination Non -Debarment E-Verify, Iran etc.) <br />Required For Change Orders Only <br />Amount of ® Increase $ 305,412.72 <br />❑ Decrease $ <br />Previous Amount $ 16,286,366.15 <br />Current Percent of Change: 1.88% <br />New Amount $ 16,591,778.87 <br />Total Percent of Change: 2.85% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Michael Divita <br />® ❑ Toy Villa <br />® ❑ Beth Leonard, Judy Love <br />