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Date <br />Name <br />9-20-16 <br />Kevin Fink <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 9-27-16 <br />Phone Extension 5903 <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 Item Type — Required for A// 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. 1C <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 />Indiana Earth Inc. <br />New Vendor <br />❑ Yes ® No ❑ If Yes Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Demolition of Vacant and Abandoned Houses, Phase IX, <br />Project Name <br />Division C <br />Project Number <br />116-074 <br />Funding Source <br />EDIT <br />Account No. <br />408.1201.415.39.89 <br />Amount <br />$103,400.00 <br />Terms of Contract <br />See Specifications <br />Purpose/Description <br />1. Change completion date <br />2. Change contract amount due to change in mulch seeding ty <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ® Increase $ 175.00 <br />F- Decrease <br />® ❑ Corbitt Kerr <br />® ❑ Toy Villa <br />® ❑ Kevin Fink <br />