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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />9-2-16 <br />Kim Thompson Department <br />Utilities <br />BPW Date 9-13-16 Phone Extension 5969 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller El greater <br />review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />M Other: Amendment <br />Company or Vendor Name <br />New Vendor <br />Yes <br />MBENVBE Contractor ❑ MBE [ <br />MBENVBE Contractor Requested ❑ No <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />uired Information <br />No LJ If Yes, Approved by Purchasing <br />WBE <br />Yes Name of Company <br />Water Works O&M <br />620-0640-658-3106 <br />$ 17,560 <br />Amendment to PSA to include business case evaluation <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination Non -Debarment E-Verify, Iran etc.) <br />Required For Change Orders Only <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />7 <br />7 <br />Kim <br />Dispersal After Approval <br />