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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date August 16, 2016 <br />Name Roger Nawrot / Corbitt Kerr Department Engineering <br />BPW Date August 23, 2016 Phone Extension 5932/5931 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller ® <br />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 <br />Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />® <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />American Structurepoint, Inc. <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />Project Name <br />South Bend Downtown Road, Traffic and Signal Improvements <br />Project Number <br />115-019 <br />Funding Source <br />TIF Bond <br />Account No. <br />Amount <br />$75,000.00 <br />Terms of Contract <br />Not to Exceed <br />Purpose/Description <br />Additional Traffic Design and Road Design Services. <br />Amount of <br />X Required Contractor's Certification Form Attached (Non -Collusion, <br />Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Chanoe Orders Only <br />Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />Nawrot <br />Approval <br />