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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 03/10/17 <br />Name Toy Villa Department Engineering <br />BPW Date 03/28/17 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael 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 />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. 8 ❑ 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 />❑ No ❑ Yes Name of Company <br />South Bend One Way to Two Way Conversion — Division A <br />116-001 <br />SSDA TIF <br />430.1050.460.31.36 <br />Approval of Change Order #8 <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 />33ount of ® Increase $ 36,810.00 <br />I-1 Decrease $ <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 />® <br />❑ <br />$ 3,469,972.80 <br />1.06% <br />$ 3,506,782.80 <br />8.62% <br />Dispersal After Approval <br />Michael Divita <br />Toy Villa <br />Beth Leonard, Judv Love <br />