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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 21, 2016 <br />Name Roger Nawrot Department Engineering <br />BPW Date September 22, 2016 Phone Extension 5932 <br />I <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name Michael Schmidt <br />Controller El <br />review is required for all Contracts $5,000.00 or more and <br />greater <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />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 />® <br />Other: Declaration of Emeraencv <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 ❑ Increase <br />CI Decrease <br />Required Information <br />Yes M No <br />❑ No ❑ Yes Name of Company <br />Storm Damaae Emeraencv Renairs <br />Declaration of an emergency to allow quotations for the repairs <br />by invitation. <br />LJ Kequirea Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination Non -Debarment E-Verify,Iran etc <br />squired For Chanoe Orders Onlv .si.. <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Chanqe: % <br />Copy <br />Origin <br />® <br />❑ <br />❑ <br />❑ <br />Nawrot <br />