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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 02/05/2024 <br />Name Becca Plantz Department Public Works <br />BPW Date 02/13/2024 Phone Extension 5998 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance <br />and Inclusion Officer ❑ Officer Name <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Michael Schmidt <br />Check the Appropriate Item Type — Required. for All Submissions <br />❑ Professional Services Agreement ❑ Contract ❑ Proposal <br />❑ Open Market Contract ❑ Amendment/Addendum ❑ Special Purchase, QPA <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes <br />❑ Proposal Opening ❑ C/O & PCA No. ❑ PCA <br />❑ Chg. Order, No. _ ❑ Traffic Control ❑ Resolution <br />M Other: Deed of Dedication n Ease./Encroach <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Information <br />3502 Oakcrest Dr. South Bend, IN 46615 <br />❑ Yes❑ If Yes, Approved by Purchasing <br />❑ No <br />❑ MBE Completed E-Verify Form Attached ❑ Nos <br />3502 Oakcrest Dr. Deed of Dedication <br />n/a <br />n/a <br />n/a <br />$1.00 <br />n/a <br />Deed of Dedication to dictate ROW along 35th Street. <br />For Change Orders Onl <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Increase <br />Current Percent of Change: Decrease <br />New Amount $ <br />Increase <br />Total Percent of Change: Decrease <br />Time Extension Amount: <br />New Completion Date: <br />