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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />8-16-2016 <br />Santiago Garces Department Innovation <br />BPW Date 8-23-16 Phone Extension 7652 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />® Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />F1 Other: <br />Company or Vendor Name Er <br />New Vendor ❑ <br />MBE/WBE Contractor ❑ <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Yes ® No <br />MBE ❑ WBE <br />❑ No ❑ Yes <br />If Yes, Approved by Purchasing <br />Name of Company <br />COIT Fund Professional Services <br />404-0672-415-31-06 <br />$ 45,000 <br />— 7/31/2016 <br />QI Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc <br />Amount of H Increase <br />❑ Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />® ❑ Santi <br />® ❑ Penr <br />® ❑ John <br />ired For Change Orders <br />Dispersal After Approval <br />3o Garces <br />Price <br />