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DocuSign Envelope ID: C52943AD-E7A1-40BD-BF8F-99DAODE88D1B <br /> ORANGE COUNTY—DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name: Jay's Chicken Shack, LLC dba Jay's Chicken Shack Party/Vendor Contact Person: Kim <br /> Mangal Contact Phone: 919-732-3591 Party/Vendor Address: 646 N. Churton Street City Hillsborough <br /> State: NC Zip: 27278 Department: Economic Development Amount: $5,000.00 Purpose: Business Investment <br /> Grant Award Budget Code(s): 34600020-900051 Vendor # N/A (N/A if new vendor) Vendor is a BOCC <br /> consultant? Yes ❑ No® Contract Type: (Check one) New ® Renewal ❑ Amendment ❑ Effective <br /> Date August 16, 2016 Approved by Board Yes❑ No❑ Agenda Date: <br /> This agreement is approved as to technical form and content: <br /> DocuSigned by: <br /> E$1.vc $ i4 , 8/19/2016 <br /> Department Director's Signature 78f4FFA(N.BE4.1n Date: <br /> Information Technologies <br /> (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is <br /> approved as to information technology content and specifications: <br /> Office of the Chief Information Officer Date: <br /> Risk Management <br /> DocuSigned by: <br /> This agreement is approved for sufficiency bqsura,Fice stAndards, specifications, and requirements: <br /> aU Vln txC 8/19/2016 <br /> Office of the Risk Management Officer 7FDCF9176800498... Date: <br /> Financial Services <br /> This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br /> Act: DocuSigned by: <br /> Office of the Chief Financial Officer �� Date: 8/19/2016 <br /> Legal Services <br /> This agreement is approved as to e3gicrciliVrid sufficiency: <br /> t 4t,S rriA, 8/19/2016 <br /> Office of the County Attorney 328DC480549A4F5... Date: <br /> Clerk to the Board <br /> Received for record retention: <br /> All DocuSign contracts must be copied to Donna Lloyd upon completion @ Dolloyd@orangecountync.gov <br /> The following signature block is for hard copies only and is not required for DocuSign contracts: <br /> Office of the Clerk to the Board Date: <br />