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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 07/18/16 <br />Name <br />Toy Villa <br />Department <br />Engineering <br />BPW Date <br />07/26/16 <br />Phone Extension <br />5920 <br />I <br />Kequired Prior to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <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 />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />® <br />Change Order No. 3 <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />F- <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 />Reith Riley Construction Co., Inc. <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />I -I MBE I I WBE <br />U No ❑ Yes Name of Company <br />South Bend One Way to Two Way Conversion — Division B <br />116-001 <br />61 <br />tsona <br />Approval of Change Order #3 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc. <br />Amount of ® Increase $ 3,822.00 <br />❑ Decrease $ <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />0.02% <br />$ 16,388,980.09 <br />0.41 % <br />Michael Divita <br />Beth Leonard <br />After Approval <br />