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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />October 18, 2016 <br />Theresa E. Harrison, P.E., ENV SP <br />BPW Date October 25, 2016 Phone Extension 5933 <br />Department Engineering <br />Division/Bureau Public Works <br />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 ❑ <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 />7 <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 ❑ Increase <br />❑ Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanqe: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />11 <br />❑ <br />u <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasinq <br />❑ MBE ❑ WBE <br />❑ No I 1 Yes Name of ComDanv <br />Resolution empowering City Engineer's Office to establish and <br />post reduced speed limit zones <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />ineer <br />Roger T. Nawrot, P.E., PLS — Assistant Citv Engineer <br />P. Corbitt Kerr <br />ired For Chi <br />dispersal Af <br />PhD, P.E. — <br />