R 2016-293-E AMS - Tibbens Construction for repair of concrete

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DocuSign Envelope ID:A495E010-63C7-4B37-9396-1C63BF41BA62 ORANGE COUNTY-DEPARTMENT USE ONLY Department Party/Vendor Name: Tibbens Construction Party/Vendor Contact Person: Mark Tibbens (Tibbensconst@aol.com) Contact Phone: 919.667.5366 Party/Vendor Address: 849 Moose Tracks Trl City Cedar Grove State: NC Zip: 27231 Department: AMS Amount: 400.00 Purpose: Repair Concrete Budget Code(s): 61370035-880000-10016 Vendor# 63556 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)New Renewal❑ Amendment ❑ Effective Date 6/10/16 Approved by Board Yes❑No® Agenda Date: This agreement is approved as to technical form and content: Us Q� Department Director's Signature Date: Information Technologies (Applicable only to harchvare/sofhvar-e ptn•chases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficiency of insurance standards,specifications,and requirements: Uocu5i9ned by: AUS0, / Office of the Risk Management Office X6" 0 Date: 6 9/2016 Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: U 5'9 dby Office of the Chief Financial Officer Date: 6/10/2016 Legal Services This agreement is approved as to legal form and sufficiency: Uocu5i9ned by: Office of the County Attorney �0� �oywts Date: 6/10/2016 Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloydgoran eg countync.g_ov The following signature block is for hard copies only and is not required for Docusign contracts: F Office of the Clerk to the Board Date: Revised 6/16 4