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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 8-17-2016 Department <br />Engineering <br />Name <br />Blair Spotts <br />Division/Bureau <br />Public Works <br />BPW Date <br />8-23-2016 <br />Phone Extension <br />5998 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: MS <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 <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 />Amount of U Increase <br />❑ Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Copy <br />Origin <br />❑ <br />❑ <br />❑ <br />0 <br />Jones Petrie Rafinski Corporation (JPR; <br />❑ Yes ® No ❑ If Yes, <br />Purchasing <br />❑ MBE ❑ WBE <br />❑ No LJ Yes Name of Company <br />Corby Boulevard Sidewalk Improvement <br />.0619-431.31-06 <br />730 <br />Not to Exceed <br />Design sidewalk along Corby Blvd between Twykenham and <br />Ironwood <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />squired For Chanae Orders Only <br />