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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/18/2018 <br />Department Public Works <br />Name Kyle.�..S.i.l.ve.us............_____.._ <br />._.................w.�___��.�.. �............................. <br />Division/Bureau Engineering <br />BPW Date 12/20/2018� <br />win uuuuwuwuwmWu <br />Phone Extension 9083 <br />mRM19999990 NAINi imiwvuMS <br />li.. ._.._.......__ .. �, ._»,.�...�...._.._ <br />..__ ..... <br />.......... ....- .._........... ...._.. - <br />Required Prior to_Submittal to Board <br />Leal <br />g ® <br />- <br />Attorney Name: Clara McDaniels <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 />Michael Schmidt <br />Check the Appropriate <br />.._ . M _....... <br />............... <br />It Type... <br />Agreement <br />❑ <br />........_� <br />�f Proposal <br />Contract Addendum <br />[ Professional Services <br />E] <br />Resolution <br />FJ Bid Opening <br />El Bid Award WReq. to Advertise Title Sheet <br />❑ Quote Opening <br />El Quote Award <br />0 Change Order No. <br />El C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />F] Traffic Control: <br />® Other: Temporary Sewer Utility <br />Easement Agreement <br />between St. Joe Regional Water and Sewer District and <br />the City of South Bend <br />�ITITmIT tawrN Information . <br />._............. �......._..._._._. <br />Company or Vendor Name <br />N/A <br />New Vendor <br />A <br />Yes No[:] Yes, proved b Purchasin�� w_ <br />MBE/WBE Contractor��� <br />MBE WBE <br />..� <br />MBE/WBE Contractor Re uested <br />q <br />.......- m,�.... �........ .....W_...... <br />No <br />_ Yes Name of Company <br />Project Name <br />Carriage Hills Sanitary Sewer Extension <br />Project Number <br />N/A <br />Funding Source <br />N/A <br />Account No. <br />...,,........... m. ,.�.......................�. <br />N/A <br />Amount <br />...� � _ _....... �..........w�... ,........... �..�...........................�a �. �...�.�.........................�_............. <br />N/A <br />Terms of Contract <br />N/A <br />Purpose/Description <br />_ <br />Granting of Easement to install a sanitary sewer on property <br />owned by the Civil City of South Bend. Sewer ownership will <br />transfer to COSB once USDA loan is maid off ��� <br />Required Contractor's <br />q Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />_Rpgy red For Change Orders <br />Amount of ❑ Increase�._. <br />❑ Decrease $ <br />Previous Amount <br />�... .... .... ._..._��� .,...m..,,,,� .... ..._.. w � ... .... ..��.w <br />Current Percent of Change. % <br />New Amount $ <br />Total Percent of Chanqe: % <br />Dispersal After <br />Copy Original <br />