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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 8/3/16 <br />BPW Date 8/9/16 <br />Name Jitin Kain <br />Department <br />Phone <br />Public Works <br />235-5835 <br />o Legal ® Attorney Name Ben Dougherty <br />M -o Controller review is required for all Contracts $5,000.00 or more <br />$ o Controller ❑ and greater than one year in length per the City Purchasing <br />i(D a` .0 m Policy <br />U) Purchasing ❑ <br />Check the AnorODrlate Item Tvne — Renuirar9 fnr All.Suhmi.cginn.c <br />® <br />Agreement <br />El Contract El Proposal <br />El Addendum <br />ElClaim <br />❑ <br />Bid OpeningEl <br />Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Chg Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ <br />Ease./Encroach. <br />❑ Traffic Control <br />❑ Resolution <br />❑ <br />Other: <br />Keauired Intormation <br />Company or Vendor Name <br />Intellectual Properties Management <br />New Vendor <br />® Yes ❑ <br />No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />Project Name <br />Fr. Hesburgh & Dr. King Monument <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Permission from the King Center to use Dr. Kings likeness in the <br />monument. <br />For Change Orders Only <br />Amount of <br />❑ <br />❑ <br />Increase <br />Decrease <br />$ <br />$ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />PO No. <br />Copy <br />Original <br />El <br />M <br />® <br />❑ <br />Linda Martin <br />Jitin Kain <br />Dispersal After Approval <br />