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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />10-18-16 <br />Public Works <br />Engineering <br />BPW Date 10-25-16 Phone Extension 5903 <br />Kevin Fink <br />Department <br />Division/Bureau <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name: Michael Schmidt <br />Controller ® <br />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. 1 <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />I-1 <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 Chanoe: <br />py <br />Original <br />® <br />❑ Corbitt Kerr <br />® <br />❑ Toy Villa <br />® <br />❑ Kevin Fink <br />Required Information <br />The AirMarking Co., Inc. <br />❑ Yes ® No ❑ If <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Jefferson Blvd. Striping Phase 1 <br />116-037A <br />Engineering Professional Services <br />101-0602-431.31-06 <br />$57,084.00 <br />See Specifications <br />I. Add three (3) calender days to contract completion date <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />equired For Chanae Orders Only <br />