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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />12/06/18 <br />Timmer <br />Department DCI <br />BPW Date 12/20/18 Phone Extension 5841 <br />mummrsir�mir�uwPomvmvi�!u�uti�rriu�mw���,m„�„� ,��,�„�.�, �;� �;u va,xa,�nnrarerinininir .. �wanwanr�m�m urvvww�iavunini wurvurvuumu�wiwuuirvw,.t�www <br />.......... ....._........ ___ ........ _.,�._ .. .�.....___________._....._..w_..�.�.�._.... m <br />Required Prior to Submittal to Board <br />.�. _ _ ..... <br />Legal ® Attorney Name Clara McDaniels Sandra Kennedy <br />Controller ® Controller review is required for all Contracts $5,000.00 or more anc <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 <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <br />Other: Amendment <br />1 Contract <br />❑ Resolution <br />❑ Bid Award <br />El Quote Award <br />C/O &PCANo. <br />Traffic Control <br />Proposal <br />❑ Req. to Advertise <br />red Information <br />❑ PCA <br />Company or Vendor Name Habitat for Humanity of St. Joseph Co. Inc. <br />New Vendor Ej Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑] WBE <br />MBE/WBE Contractor Requested ® No F Yes Name of Company <br />Project Name _„Aois�Non / eha bilitation Activity <br />Project Number 16-JC-11 (02) <br />Addendum <br />❑ Title Sheet <br />Funding Source <br />Community Development Block Grant (CDBG) <br />Account No. <br />212.1001.460.39.30 <br />Amount <br />000 (no increase in original cont <br />$103, contract amount) <br />Terms of Contract <br />1 /01 /16.._.12/31 /19...._____.. m. <br />Purpose/Description <br />Extend timeframe of on inal contract by 12 months through <br />12/31 /19 <br />® Required Contractor's Certification Form Attached (Non - <br />__Collusion„ <br />Non -Discrimination, Non -Debarment, E-V+arif , Iran,, etc. <br />euired For Change Orders Only <br />Amount of ❑ Increase <br />$......._.� <br />❑ Decrease $ <br />Previous Amount <br />....... ......... _ ... ....... —--- ,.---- .......... <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />m�. <br />% <br />Dispersal After Approval <br />Copy Original <br />El El <br />El R <br />