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Date <br />Name <br />BPW Date <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />3/20/17 <br />Kara M. Boyles <br />3/28/17 <br />Department Engineering <br />Division/Bureau DPW <br />Phone Extension 5933 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: M. Schmidt <br />Controller El greater <br />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 />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />Proposal <br />❑ Resolution <br />Addendum <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Award <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control: <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 />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Required Information <br />St. Joseph County Regional Water and Sewer District <br />U Yes 0 No U If Yes, Approved by <br />Purchasing <br />❑ MBE U WBE <br />® No ❑ Yes Name of Company n/a <br />Addendum No. 2 Carriage Hills Subdivision Sub -District <br />N/A <br />N/A <br />N/A <br />District to become a customer and provide sanitary sewer <br />service to their customers within Carriage Hills subdivision. <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />For Chanqe Orders O <br />