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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/31/2016 <br />Name Becky Bonham Department <br />BPW Date 9/13/2016 Phone Extension <br />Required Prior to Submittal to Board <br />Legal x Attorney Name Michael Schmidt <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />® Agreement <br />❑ Contract ❑ Proposal <br />❑ Addendum <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise <br />❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Chg Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease./Encroach. <br />❑ Traffic Control ❑ Resolution <br />❑ Other: <br />❑ Claim <br />Required Information <br />Company or Vendor Name <br />South Bend Civic Theater, Inc. <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />New Vendor <br />® No <br />MBE/WBE Contractor <br />� WBE Completed E-Verify Form Attached <br />No <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 />Effective Oct. 1, 2016 <br />Cancel lease for Portage Ave. Fire House, 701 Portage Ave. per <br />terms of Lease Extension Agreement <br />For Change Orders Only: <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispersal After Approval <br />Bonham, South Bend Civic Theater <br />