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BOARD OF PUBIAC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/19/2017 <br />Name Sue Ellen Doudrick <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 12/21/2017 Phone Extension 5922 <br />Required Prior to Submittal to Board <br />Legal Z Attorney Name: Clara McDaniels <br />Controller Z 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 1:1 <br />Agreement Amendment <br />H Contract H Proposal Ll Addendum <br />Professional Services <br />F� Resolution <br />Bid Opening <br />F] Bid Award El Req. to Advertise El Title Sheet <br />Quote Opening <br />Z Quote Award <br />Change Order No. <br />❑ C/O & PA No. F-1 RCA <br />Ease/Encroach. <br />❑ Traffic Control: <br />Other: General Release <br />Company or Vendor Name The Airmarking Co., Inc. <br />El Yes F] No ❑ If Yes, Approved by <br />New Vendor Purchasinq <br />MBEANBE Contractor <br />MBEANBE 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 />% Fall a 0 VIVOIN <br />H No L] Yes Name of Compan <br />Downtown Bridge Striping <br />117-129 <br />LSRA / Lane Markings & LSRA I Street Maint. <br />251-0608-431.42-93 ($27,000.00) — use this account first <br />251-0608-431.36-10 ($45,500.20) <br />$72,500.20 <br />Provide and install pavement striping and markings on several <br />streets and bridges located downtown South Bend, Indiana. <br />[] Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Copy <br />Original <br />E <br />F] <br />M <br />F] <br />n <br />El <br />Sue Ellen Doudrick <br />Alicia Czarnecki <br />