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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 6, 2016 <br />Name Roger Nawrot Department Engineering <br />BPW Date September 13, 2016 Phone Extension 5932 <br />L Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael 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 ® George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑Contract ❑ Proposal ❑ Addendum <br />® <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />n <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 Chance: <br />Copy <br />Original <br />® <br />❑ <br />Fisher Associates P.C. <br />No [ <br />] WBE <br />Yes Name of Compa <br />cy Repair of Ireland Ro <br />11 <br />Major Moves <br />412.0602.431.42.03 <br />Qo nnn nn <br />Road <br />Not to Exceed <br />To prepare bid documents to repair the pavement and shoulder <br />washout out caused by the August storm.. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />ired For Change Orders <br />Roger Nawrot <br />DCI — Jitin Kain <br />Lawson — Fisher P.C. <br />