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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />06/27/2016 <br />Nadia Correa <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 07/26/2016 Phone Extension 5796 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <br />Controller ® 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 ® George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />® Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor 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 />vson-Fischer Associates <br />Yes No <br />If Yes, Approved by <br />U MBE U WBE <br />❑ No ❑ Yes Name of Company <br />South Bend Dam Underwater Inspection and Bathymetric <br />116-071 <br />Professional Services <br />101-0602-431.31-06 <br />1 <br />To be completed by December 31, 2016 <br />FERC permit requirement to inspect scour at base of dam <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Chanoe: % <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />Cecil Eastman <br />Therese Dorau <br />